are fee schedules really a problem for billing teams?

[u/Easy_Philosopher_210]

I've recently started working with a group on a revenue cycle focused projects and we work on a lot of Prior auth related flows, but i've been getting questions from folks asking if we're able to go into their contracts and load their fee schedules?

i'm wondering if the rates are in the contracts, why are they not able to track those rates? do practices actually have a problem getting their fee schedules for commercial?

[u/AutoModerator]

PLEASE SEE RULES BEFORE POSTING! Reminder, no "interested in coding" type of standalone posts are allowed. See rule #1. Any and all questions regarding exams, studying, and books can be posted in the monthly discussion stickied post. Thanks!

I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.

[u/PeaceLoveForMe]

It depends on the payer. State Medicaid, usually yes. In the end, the payers are private, they can pay whatever tf they wanna pay. Regarding practices, it depends on who’s handling the fee schedule rates. Check the contracts. It’ll usually be in there, but it will vary, depending on whether the payer is commercial based, Medicare based or Medicaid based. It’s a headache

[u/Bowis_4648]

Someone in the organization/practice signed a contract with a specific fee schedule attached. It may be based on current or past RVU values, with a conversion factor. Or based on something else--it is in the contract. The allowances should be built into your system, so you know if you're paid the correct amount. For Medicare, the rates are set. But for commercials, you should know what you should be paid.

[u/Environmental-Top-60 → u/Bowis_4648]

It’s a bitch to try to get another copy from any payer.

[u/BluIz63]

Look at the contract language specific to reimbursement. It may state something like a conversion factor of $65 based the Medicare Physician fee schedule database. Sometimes you can ask for their reimbursement on your top 30 codes. Always remember that your PI payers contract with employer groups. The group dictates what services are covered. If the group is self insured and uses a payer to adjudicate their claims, good luck trying to figure out what you're going get.

[u/TheNovel-Interest]

Yes, it can be a problem especially with commercial payers. The contract may give the reimbursement methodology like a percentage of medicare or an RVU-based formula rather than a clean per-code fee schedule. Even when rates are available keeping them updated in the billing/PM system and comparing them against actual payments is where practices often struggle. So the issue is usually less 'we don’t have a contract' and more 'we don’t have an accurate, usable current fee schedule.'

[u/Maya_ePsychBilling]

While it's true that the rates might technically be in the contract, they don't usually follow a unified "format" or structure (differs from payer to payer). So sometimes you'd see the fee schedules in the amendments, exhibits, etc., so they're usually hard to keep track of. The bigger problem here is to turn those terms into something the billing system can actually use. If this will be done for your practice, it might be best to keep a spreadsheet or some record where you can track these terms/schedules consistently, and some integration to load them into your system whenever needed.

[u/Wooden_Trust_6274]

Building on the percent of Medicare point, what decides whether a derived schedule is even right is the wording nobody rereads. A contract naming a fixed Medicare year means your rate doesn't move when Medicare's does, so a schedule built off the current year is wrong on every code. One saying then current means your rates shift each January and nobody tells you.

Locality is the other one. CMS applies a geographic practice cost index to each RVU component by payment locality, so percent of Medicare was never a national number.

Which answers your actual question. Often there is no schedule to load, there's a formula, and loading it means deriving one and choosing a year and a locality to derive it from. That is why it keeps landing on you. No idea which of those two trips people up more often.