Re: Insurance Billing Charges

[Guest guest]

I would caution against billing any insurance company by their fee schedule.? I

would ALWAYS bill at my fee schedule rate.? Why?? Because insurance companies

still use USUAL, REASONABLE and CUSTOMARY (URC) fees when processing claims.?

They throw your charges into their database along with every other therapist in

your zip code region.? They determine the average charge and benchmark their URC

rates accordingly.? So if you bill at their profile rate, guess what?? You have

just brought the average URC down and potentially directed your fee toward a

reduction.

Bill everything out at your standard fee.?

Jim <///><

Insurance Billing Charges

I have been informed that we should bill the same charges for services

accross the board for all payers, be it insurance, medicaid, or

private pay. We have signed a contract with some insurances for an

" agreed amount " of reimbursement and Medicaid has a set rate. Other

insurances that we do not have an " agreed amount " contract on could

possibly pay more which is why it was suggested to me to bill one rate

accross the board.

Our clinic does PT, OT and Speech on a 15 minute unit and we treat

mostly Medicaid clients but with a growing caseload of insurance

clients. It was suggested to me to charge $45 per 15 minute treatment

unit for each discipline.

My question is this: Should we do this and is it legal and/or ethical.

If we do this and have a private pay client and want to give them a

break how do we do so? Any help would be appreciated.

[Guest guest]

Dear ,

It may behoove you to check with your Medicaid FI to determine if, as a Part

A provider/CORF, you have the option of billing " full bill charges " or must

bill Medicaid/FI a predetermined/flat rate per unit.

With regard to commercial/group health carriers, third party liability

carriers, and uninsured/underinsured/self-pay patients, I would recommend that

you

first determine what it actually cost your practice to perform each

procedure by discipline prior to adopting and implementing a " standard " or

" master "

fee schedule. Why is this important?

Unless you pay your PTs, OTs and SLPs the exact same salary and offer them

the exact same benefit package regardless of their experience/years of

service, you will likely find that there is a marked difference in what it cost

your

practice to provide these three therapy disciplines.

Unfortunately, commercial/group health insurance carriers have been slow to

recognize the value and medical necessity of outpatient OT and SLP provided

in conjunction with outpatient PT, resulting in many patients being forced to

assume more financial responsibility and/or higher out-of-pocket cost when

they have an injury or disease requiring all three disciplines. Additionally,

many commercial/group health insurance carriers limit the number of covered

OT visits a policyholder or subscriber is entitled to receive during a

calendar/policy year (i.e., 20 visits per year), and offer absolutely NO

coverage

for SLP.

We have had clients who only provide outpatient PT services, clients who

only provide PT/OT services, and clients who provide adult and pediatric

PT/OT/SLP services. Our companies have provided practice management, accounts

receivable management, and third party billing services to over 70 PT/OT/SLP

providers in the sate of Louisiana in the past 8 years. As a result, I can

personally attest to the fact that practices that offer multi-discipline

therapy

services not only have higher overhead costs, but also have higher denial

rates, higher number of AR turnover in days, higher patient vs. insurance

balances, higher employee turnover, lower net/gross collection ratios, and

lower

profit margins as compared to those practices that elect to specialize in one

discipline.

The one thing that has consistently surprised me when servicing

multi-discipline therapy clinic owners is there seems to be more emphasis

placed on

" patient treatment " and less emphasis on " profits. " This is not to say that

single-specialty therapy clinic owners place more value on " profits " than on

" patient treatment, " but instead to say that single-specialty therapy clinic

owners have more time to focus their efforts on effectively and profitably

managing their practice, as compared to clinic owners that must deal with

billing,

coding, and documentation changes that serve to impact practice reimbursement

for three different disciplines.

I would not advise you to adopt ONE " standard " or " master " fee schedule for

PT, OT and SLP services, i.e., " $45 per 15 minutes for PT/OT/SLP services. "

Instead, I would recommend you base your standard fee schedule on RVUs by

procedure and discipline, as well as considering your payer mix and

demographics. Respectfully, while it is important that you base your standard

fee

schedule on what other PTs/OTs/SLPs are charging in your geographical

local--for

insurance profiling purposes--an inflated AR will make it considerably more

difficult, and in some cases impossible for you to determine if your practice

is

experiencing serious billing and collection problems.

Hope this helps and wishing you the best of luck in the future.

Vickie

D. Cavitt, President

Medical Legal Alliance, LLC

337250.0112

In a a message dated 9/19/2008 6:32:56 A.M. Central Daylight Time,

JHall49629@... writes:

Every billing software program that is worth its weight has the ability to

set up an insurance company's payment profile.? Let me take a second to

explain.? As a company, you should establish a charge master that all payers

get

billed.? If you decide that you want to charge $45 per 15 minutes of direct one

on one therapy, then that is what each and every insurance company and

patient?should be billed.? However, when you sign up as a participating

provider

with Medicare, BCBS and any other provider, you are agreeing to accept the fee

schedule they are imposing on you in return for sending you their patients.?

Each insurance company can have their own fee schedule.? You still send your

claims out with the $45 per 15 minute charge.??But you agree that you will

write any difference between what you charge and what their fee schedule is

off.? So, if their fee schedule pays $25 per 15 minutes it would work like

this:

You charge $45 to the insurance company.? They process your claim and

approve $25 for that procedure.? Their check/explanation of benefits comes back

stating they approved the 15 minute treatment at $25 (as per your contract) and

you have to write off $20.?

I have over simplified, but hopefully you understand from the example.

Good luck,

Jim Hall, CPA <///><

General Manager

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

Insurance Billing Charges

I have been informed that we should bill the same charges for services

accross the board for all payers, be it insurance, medicaid, or

private pay. We have signed a contract with some insurances for an

" agreed amount " of reimbursement and Medicaid has a set rate. Other

insurances that we do not have an " agreed amount " contract on could

possibly pay more which is why it was suggested to me to bill one rate

accross the board.

Our clinic does PT, OT and Speech on a 15 minute unit and we treat

mostly Medicaid clients but with a growing caseload of insurance

clients. It was suggested to me to charge $45 per 15 minute treatment

unit for each discipline.

My question is this: Should we do this and is it legal and/or ethical.

If we do this and have a private pay client and want to give them a

break how do we do so? Any help would be appreciated.

[Non-text portions of this message have been removed]

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