Question on provider procedure charges and question on billing service transition

by Claire
(Mission VIejo)


I will be opening my medical billing service in a few months and I would like to know how to price the procedures that I will bill to insurance.

I was told that the fee schedule for all insurance is based on CMS's fee schedule and that providers usually multiply that fee by 10(x10) as their "usual charge", can you confirm?

Also, the software company I will be using will handle the transition of the provider's data from the old billing service to my software. Do I only get the current open claims or is the aging claims also my responsibility?

Any information you can provide would be greatly appreciated.


I’m not familiar with the x10 as a general rule for pricing a provider's procedures but welcome our visitors comments below.

The only approach we’ve recommended to our providers is to price their procedures sufficient to cover the pricing that insurance payors have negotiated on behalf of the patient. Of course this varies with each insurance company with Medicare/Medicaid typically being the lowest. I had one provider that wasn’t charging enough for some procedures and therefore wasn’t getting reimbursed the full amount allowed.

As far as your second question regarding what claims are your responsibility, I would suggest discussing and negotiating with your provider. I know some billing services only want to be responsible for new claims going forward. As you may know working on aging claims can require significantly more time and effort on your part - especially if you weren’t responsible for the billing.

For that reason if you do end up working the old aging, I would suggest charging a higher fee to cover your additional time and effort to work these. I know some services charge over double what they would for normal claims. It seems like the older a claim is, the harder it can be to get paid.

Hope this answers your questions. Thanks and good luck.

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