New Client Needs Help With Fee Schedule

by Tracy
(New Jersey)

I recently obtained my first client. I am new at this so I need all the help I can get. The APN is just starting out and does not know anything about billing (how much to charge for services). How do I get access to the fee schedules, benefits and eligibility from the insurance companies. I your assistance will be greatly appreciated.


Response:

The American Medical Association (AMA) has a good article setting your fee schedule here.

Each insurance company has their own fee schedule for what they pay a provider depending on their contract. There are so many and they change so routinely that any links to the major insurance payers would soon be out of date.

You typically have to get it from their website which usually involves creating a provider account. If your provider already has a contract with them, they may already have an account.

Medicare posts their fee schedule on their website (cms.gov). Just go to their website and search for "physician fee schedule" to get the latest. They also have a fee schedule look up tool.

Hope this helps - Thanks!

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May 30, 2017
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Setting Fees - New Practice
by: Chris Zaenger CHBC

Anyone who takes the Medicare Fee Schedule for their area or their State Medicaid Fee Schedule and uses it as their practice fee schedule will leave thousands of dollars on the table every week or month.

Since most payers around the country use a % of RBRVS as a reimbursement rate, the CMS Posted fee schedule (except for non-covered services) offers ONLY a starting point. The CMS Federal conversion rates have little to do with commercial payers. Payers decide their allowed amounts based upon actuarial computations, competition, premium population demographics and medical history and experience, and a number of other factors, including required margins.

Setting aside the additional $$$ now available through the RAF (risk adjustment factors) results per claim, that can increase or diminish reimbursement, the determination of an allowed amount per CPT code will be some percentage lower or much higher than the CMS rate.

Get help from someone who knows how to do this in your specific market. Knowing payer limits helps and knowing the overhead cost of delivering a service or product is also most helpful.

AAPC, NSCHBC, MGMA, AMA, and other non-profit association groups can guide you. All my best.

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