office procedures

[lonelobo]

For last five years I have done procedures in ASC and we are moving
to mainly office based procedures. Meidcare will make this worth it for us
as case mix is 50% MC.
We are still negotiating with contracted plans for a change in fee schedule
for site of service differential.

My question for those of you doing office procedures is, what is patient responsible for paying up front?
-just office copay?
-same rate as outpatient surgery? ie 20%, 30%
-obviously deductible needs to met

any ideas, suggestions?

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[Pain_doc]

Nearly all payors have fee differentials. Office-based procedures co-pays are the same as specialist office co-pays. The percentage co-pays, like for surgery centers, are different. I'm assuming that your facility will not be classified/certified as a surgery center. It's important to know your reimbursements, as any payor that does not pay differently, you'll want to continue to do at the surgery center. As a solo doc, I have limited bargaining power. Nonetheless, I attempt to negotiate on a few CPT codes. Look at what is done most frequently or what utilizes the most resources and attempt to re-negotiate those codes. Good luck.

 

[TX PAIN DOC]

We always call the private payors and precert the procedure prior to scheduling it in-office. That way the patient will always knows their portion (deductible taken into account) and we know whether it is a covered benefit. Our office manager negotiates reimbursement on the most used CPT codes yearly.

 

[Aether2000]

In my area, only Anthem and Medicare have a site of service differential, and these two entities constitute 2/3 of my patients. Neither will pay a facility fee. Both have set rates and do not negotiate these rates with independent physicians not part of a large physician group. Patients are responsible for both copays (by law) and deductables (by law). Therefore we collect at the time of service, and cheerfully accept Visa, Mastercard, American Express, and small chickens.

 

[lobelsteve]

In my area, only Anthem and Medicare have a site of service differential, and these two entities constitute 2/3 of my patients. Neither will pay a facility fee. Both have set rates and do not negotiate these rates with independent physicians not part of a large physician group. Patients are responsible for both copays (by law) and deductables (by law). Therefore we collect at the time of service, and cheerfully accept Visa, Mastercard, American Express, and small chickens.

Those are game hens and are worth a single level MBB each.

 

[bedrock]

It's important to know your reimbursements, as any payor that does not pay differently, you'll want to continue to do at the surgery center.

I'm confused. Do some insurance companies pay the same physician fee whether the procedure was done in office or in an ASC? (The same lower fee that you get in an ASC?)
I guess I was under the impression you always got paid more for everything you did in-office vs ASC/hospital.

Medicare have a site of service differential, and these two entities constitute 2/3 of my patients. Neither will pay a facility fee.

Does medicare differ regarding this from state to state? I do few medicare patients each month at an ASC, and I don't hear back about it from the ASC.

 

[PMR 4 MSK]

I'm confused. Do some insurance companies pay the same physician fee whether the procedure was done in office or in an ASC? (The same lower fee that you get in an ASC?)
I guess I was under the impression you always got paid more for everything you did in-office vs ASC/hospital.



Does medicare differ regarding this from state to state? I do few medicare patients each month at an ASC, and I don't hear back about it from the ASC.

Many private insurances will pay you, the injector, the same regardless of where you do the injection. What they pay differently is for ASC fees and/or the TC of Fluoro.

ASCs negotiate rates with private insurance. Medicare pays flat rates for procedure groups (a couple years ago, our ASC got $333 for most procedures I did there, I believe it is less now).

If you have the fluoro in your office, the amount you get paid for 77702/3 is usually higher in the office than what you would get in ASC or hospital.