I know that this is one of my long posts, but it really is full of important information, that we paid dearly for to learn via membership in the IPA/PO as well as consultants, and now you get to share in on it for free as my starving friends here at the AC user board. So don't say we never gave you anything. Anyway, read careful and understand. BTW, you're welcome....
I think the problem the confusion here is that people tend to use the same term for two separate but similar concepts. We the providers have our "fee schedule" our bottom line, "charges". This is the term to use to distiguish your fees verse anything else. As the law basically states (which is a complete joke, but the f'ing cartels own our gov't and so here is the intent of the law) we must "charge" everyone "Equally". Now obviously we don't because these bastards demand and force upon us whatever they are willing to pay. We can't sit there and say, "screw you I charge $75 here for this level 3 pay up or shut up", nor can we even balance bill the patient for the difference between our $75, the carriers cheap@$$ $50 for a difference of $25. But all of that not widthstanding, we MUST charge everyone equally, as though we are treating people separate and unequally, really no CCHIT. So the safe and basically legal thing to do, is NO MATTER WHAT, all invoices, bills, 1500's must have the same charge for the same code on them... Period short the end. To do otherwise is to risk the almost certain wrath of hell from the carriers and the gov't alike. (we will get back to that in a moment)
Now there are also the carriers' fee schedules (although try calling them up and actually getting a full print-out or excel file with your "agreed upon rates" even though you have a contract that states this contracted rate exsists! Simply Amazing. This is allowed to continue like this, they are anti-trust waived while we have those same laws strickly enforced upon us for these corporate giants).
So most quality PM modules, programs will allow you to enter various fee schedules for all the carriers and even products (since there is usually a difference even amoung these too) too. Different programs have various different levels of control, reporting, and FLAGGING, of your charges verses the carriers payments or fee schedule. I am in the process of investigating for purchase and perhaps even becoming a VAR for a particular product because I believe as memory serves me, they even had a good "Flagging" of these differences and write-offs. So let's use the same numbers again.
You charged $75 for a level 3, you have entered $50 as your excepted payment (minus co-pays of course) for this code (99213) for a certain carrier (@ETN@) but the sob's only sent you a payment of $45 dollars (assuming no copay here for the moment) a really good program should do some form of "flagging" of this under payment (which they do all too often, hoping that we won't notice buried in a large EOB and batch of payments, no less do we really want to waste $10 of staff time fighting for $5... But this is a fair fight right?) so you can be aware of it and hopefully attend to it. I swear that their software must even have randomiszed under payments in it so it goes out very sporatically so it is hard to spot a trend except between practices and because we are not allowed to talk (except in certain IPO/PO type situations where both sides have agree to commom terms and conditions for all members of the group). Nice right? But these guys are the victims here, of us terribly criminal, stealing under hadned providers??? Yeah, right!
Now the real issue of breaking the law is to "charge" different people of companies, carriers differently. So like so many of you probably do, (which we really and honestly never do, I will not put my wife the mother of my kids at risk to save someone $10) is to give let's say a cash paying customer a $10 discount for cash on the barrel at time of service, even if you DO NOT PAR with this person's carrier or product.
Because the gov't and the carriers will come back and throw those 'discounts" in your face and claim that you don't really charge $75 for a 99213, you are really only charging $65 for this code, based on your collection from cash patients. Now whether they must at least or you can get them to at least do some sort of add and divide math here, to balance out all your charges is another matter, because you are already back on your heels playing defense at this point trying to hold off the tidal wave coming at you.
They will try and will probably will win, give backs for your "over charges" even if you don't actually get in legal trouble for insurance fraud for "over charging" them even though they only paid you $50! No CCHIT. And how do they finally get you and your expensive lawyer to agree to all these undeserved give backs??? Obviously with the threat of charges of insurance fraud held over your head, that's how. So even though they don't even pay you enough to make up the difference here, they will use this ammunition against you, and they will. These SOB's do it everyday....
Trust me on this, and it varies from state to state. The word around NYS is they are very big in prosecuting these types of things here in our fine state. And then there is the worse kind of fraud charges that come from Medicare and Mediciad. And don't forget because you have contracts and have legally signed on with all these various products and programs the carriers and the gov't have full "rights" to come on in and look at almost anything they want at almost anytime they want to. You have no real choice in most situations but to let them in to look at the charts and the billing too. Now obviously if and when any of you ever get that terrible phonecall or letter stating they are coming and want in NOW, don't let them in right away, stall for time just a bit and call both your private healthcare attorney, possibly your inept medical society and your malpractice carrier's legal dept too.
So the bottom line is there are your charges, what the sob's will pay, and that is the difference in fee schedules. But even for the carrier that pays you $50 for your $75 99213, always submit a bill, an invoice, a 1500 for your always the same charges of $75. And if you care to stay safe and our of the reach of these SOB's still charge even your cash on the barrel patients the same. No cash discounts, no matter how much this pulls at your heartstrings. Where will any of these folks be for you when Medicare comes and tears you and your office apart? No where to be found...
Well on that happy note, have a great weekend and enjoy taking it up the shoot on all your charges.....
Paul
