How much to charge for services

[PGY2]

Hello,

I am new to private practice and would like to know what you guys are charging for the following:

1) new patient evaluations
2) follow up office visits
3) consults - in office
4) hospital consults

I know what you get paid is dependent on your contract with the different payors, but what do you actually put down on the HCFA forms for the amount to charge?

Thanks in advance for any responses!

RG

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[Tenesma]

i would say it is pretty safe to get a medicare schedule and then multiply anywhere between 2 to 4 times for your charges - that way you should capture most private payers...

 

[mille125]

i would say it is pretty safe to get a medicare schedule and then multiply anywhere between 2 to 4 times for your charges - that way you should capture most private payers...

i agree... the key is to make sure that your charges are high enough to capture all payers. The actual number doesnt really matter.


For instance.... a level III followup from medicare is near $60. Highest commercial payer is near $120...As long as your charge is above 120, it isnt a real big deal unless you have a lot of private pay patients. But if your charge was $110 then you are leaving money on the table.


For private pay you can give a prompt pay discount without running afoul with your commercial contracts (however they do need to pay promptly)...

 

[ampaphb]

i would say it is pretty safe to get a medicare schedule and then multiply anywhere between 2 to 4 times for your charges - that way you should capture most private payers...

I know your numbers are exactly what I have always been told, but no one has ever explained to me what the down side would be to having your multiplier be 10x, just in case you happen to hit the jackpot occasionally.

 

[mille125]

I know your numbers are exactly what I have always been told, but no one has ever explained to me what the down side would be to having your multiplier be 10x, just in case you happen to hit the jackpot occasionally.

The downside would be for a cash pay patient

 

[mille125]

I know your numbers are exactly what I have always been told, but no one has ever explained to me what the down side would be to having your multiplier be 10x, just in case you happen to hit the jackpot occasionally.

Also, you need to be careful because many insurance plans are looking at our billed charges and making decisions about "tiered networks" you may appear very expensive to them if your office visit is $1100 and the average in the area is $300

 

[Doctodd]

also if you see Auto or PIP patients you may be deposed as to where you get your fee schedule. To just say i muliitply it by whatever wont be the correct answer and the insurance company will win the case, and you wont get paid most likely. There is a book with percentiles of what other docs charge based on zip code that you can use to answer that question.

T

 

[lobelsteve]

So why not bill $1 over your highest contracted reimbursement rate (from your best paying insurer).

Kind of a Price is Right strategy. I do not know if WC requires the same billing as all other payors, but they have a fee schedule as well.

???

 

[Tenesma]

what the insurances look at is the %ile in your region....

typically 3-4 x medicare is 90-95th percentile... if you go much beyond that then mille is right should it go to court...

AND the insurances are leaning more towards "usual and customary fees" where they determine what is acceptable based on previous charges and regional charges.... so charging 10k for a 99244 will get a lot of laughs and the jackpots we used to hear about are things of the past...

 

[Doctodd]

So why not bill $1 over your highest contracted reimbursement rate (from your best paying insurer).

Kind of a Price is Right strategy. I do not know if WC requires the same billing as all other payors, but they have a fee schedule as well.

???

to bill $1 over is easier said then done....since each insurance has different plans it is really hard to tell who will pay what. Example....i just got a full payment from one insurance company for the initial exam....$600. I rarely see it especially from them, but it does happen. I turned down their contract rate to be in network....worked for me in this case.

 

[Tenesma]

todd brings up a good point - it is important that you (or your billing staff) routinely screen remittances/payments to catch those insurances who are paying you in full... cause when they do that may mean you are under-charging

 

[Kwijibo]

Sometimes you can get what you ask for and it doesn't look good. When you are billing 5K for a two level transforaminal injection and you get reimbursed 500$ it can make you look pretty silly.

Also,
Doctodd, can you recommend anyone in the Miami/Ft. Lauderdale area that does vertebroplasty?- you can pm me.

 

[ampaphb]

Sometimes you can get what you ask for and it doesn't look good. When you are billing 5K for a two level transforaminal injection and you get reimbursed 500$ it can make you look pretty silly.

The day the one carrier pays you your $5000, it seems a whole lot less silly, however

 

[Tenesma]

at what point does it become fraud (ie: bilking)... just curious...

clearly we'd all love 5k for an ESI...