On this page
- Charges
HCET Home > On-line Training > Money Matters > 4. Charges
4. Charges
The first step is comparing your fees to your Medicaid reimbursement rate. They MUST be equal to or higher than their rates.
- Charges must be based on what it costs to provide services
- Charge floor (not ceiling)… Medicare fees are an important standard
- Maximal charge should be 125% to 150% of Medicare fee. If you are at 140% of Medicare fee you should be okay
- The Medicare fee is, generally, about 85% of the physician reimbursement schedule for the area. This is the amount you will find on the procedures workbook and as the relative value on forms one and two
| Examples
WI RVU for 99203……………… $88.71 You can safely charge $94.00 to $106.00 |
- Charges can be generated based on office visits, consultations, procedures, diagnostic tests, X-rays, injections, vaccinations, and/or supplies.
- Supporting documentation (including who provided the service) has to be located in the progress notes, laboratory reports, X-ray reports or diagnostic services reports.
- If services are provided in multiple sites (e.g., exam room and lab), charges have to be collected and organized for billing purposes. A data collection or encounter form is the best way to do this.
- Physicians and mid-level providers can make entries in the record and may generate charges during a patient visit. (For WI Medicaid nurse charges will apply, as well.)
- All payers have specific guidelines about how to submit claims for non-physician charges. Some payers may credential non-physicians to allow charges to be submitted under their own provider number. Others only allow billing under a physician. You will be paid the lesser of your charge or their payment level, so you need to update your fee structure to be sure it is high enough!
- Whatever the rules, be sure that your health record documentation backs up the billing.
 |
If the note is not in the record, then the visit did not happen. And it will not be paid. |
- Verify MCO (HMO) fees, and charge more than they pay (30-35% adjustment, on average).
- Charges should be consistent with other providers in the area.
- There are ways to determine if your fees are competitive. For example, the HCPCS Fee Analyzer is a guide to constructing fee schedules for the large variety of HCPCS supplies and services, evaluating payer contracts for adequate reimbursement, and negotiating with suppliers for competitive prices.
- You need to pay attention to profit and loss. Programs can generate a “profit” which we may call “margin” or “excess.”
- Depreciation- recognizes annual value with reduction of value. “Profits” can fund depreciation.
