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The number one question at all my meetings! “How can I get Medical Insurance to give fees”?

Getting The Real Story On A Payer’s Fee Schedule
You have begged and pleaded and finally received the gold mine of information – the payer fee schedule! But, do you have the whole story about how the payer will, or won’t, pay?

A complete fee schedule is more than just a list of the Current Procedural Terminology (CPT) codes and the associated contracted rate for your top procedures.

In fact, it is quit possible that many of the contracted rates listed on the fee schedule would rarely be reimbursed at the listed value. Why? Because there are many internal reimbursement rules that apply to the fee schedule rates which routinely reduce the amount paid.

The American Medical Association recently released a checklist to use when requesting a payer fee schedule. The checklist, which is part of the publication entitled “Evaluating and Negotiating Emerging Payment Options”, gives healthcare organizations a better understanding of just how comprehensive reimbursement information needs to be for accurate payment projection and contract compliance monitoring. Further, the focus of the publication is to prepare healthcare organizations to negotiate better deals with plans who are building more risk-based contracting terms into managed care contracts.

“Do not be satisfied with generalities – information provided to you by the health plan needs to contain detail sufficient to enable you to determine what your actual payments will be,” states the AMA publication which is available at http://www.ama-assn.org under the online group, “Cutting-edge Contracting.”

The following items appear on the fee schedule review checklist:

Does the fee schedule describe each procedure and service with an applicable CPT, HCPCS, ASA, and any applicable modifiers?

Has the health plan disclosed all the payment rules, coding edits, modifiers and other factors that it will use to calculate payment amounts? For example, has the health plan disclosed: specific payment rules regarding consolidation of multiple services or charges; reimbursement for assistant surgeons, reimbursement for the administration of immunizations and injectable medications; definition of global surgery periods, etc?

To what extent will the health plan use nationally recognized, generally accepted CPT codes and guidelines, including all relevant modifiers, and to what extent will that use be consistent with nationally recognized, generally accepted bundling edits and multiple procedure reduction logic?

Has the health plan disclosed the publisher, product name, edition and model version of any software that will be used to edit your claims?

Has the health plan provided you with all information, including but not limited to, all fee schedules, payment rules and coding edits that the health plan will use to calculate payments due to you under each of the products in which you will participate?

Will the health plan provide you with actual payment examples using combinations of CPT codes for services that you frequently perform so that you can fully anticipate actual amounts that you will receive under the contract?

The checklist goes on to cover a number of other items which enhance reimbursement transparency and provide organizations with more precise reimbursement information.

Further, the AMA publication, written in part by Wes Cleveland and Catherine Hanson, discusses the role fee-for-service will play in the future as health plans redesign coverage to align and comply with the Affordable Care Act (ACA). The free publication covers a number of potential scenarios under which fee-for-service might be retained under a more risk-based contract.

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