Case Study: Regular Charge Fee Schedule Review

August 18, 2022

By: Billie Mildenberger, Director of Audit Services

Background:

Setting up and reviewing your charge fee schedule regularly is crucial to ensuring your practice is not leaving money on the table. It is important to review all payor contracted rates when setting up/reviewing your charge fee schedule. The Centers for Medicare & Medicaid Services (CMS) releases the following calendar year (CY) Medicare Part B Physician Fee Schedule (MPSF) Final Rule in the beginning of November, which goes into effect Jan 1st the following year. These rates should be reviewed to help you determine appropriate charges for your fee schedule.

Best Practices:

Vachette recommends setting the charge fee between 150-250% of current calendar year Medicare Physician Fee Schedule.

Do not charge different rates based on insurances or self-pay. You may develop a policy for self-pay discounts if you would like to reduce self-pay rates.

Review your charge fee schedule regularly to ensure your group is charging up to the payor contracted allowed amounts.

Examples:

Vachette identified a client who had their fee schedule set at a rate that was lower than some payor fee schedules. When we reviewed the payor allowable compared to the rate the group was charging, we determined that the group could have increased their revenue for the year in review by at least $5,342 if they had aligned their rates according to the payor allowable.

CPT CodeCharge FeeMedicare AllowableLoss Per CPTVolumeTotal Loss
88309$375$403.10$28.10142$3,990
88312$100$103.92$3.92345$1,352
Grand Total$5,342

Commercial payor contract fee schedules are commonly greater than the Medicare Physician Fee Schedule, meaning the total loss was likely greater than this estimate.

Resolution:

Based on our review and recommendation the biller updated the charge fee schedule to ensure all rates are above payor contracted rates.

Why do we audit?

Vachette completes a quarterly audit for all of our full-scope clients to ensure that processes are tight, well defined, and effectively communicated. 

Our audit process includes a thorough analysis of the revenue cycle, from charge capture to 100% adjudication (either payment, adjustment, or write off) – determining if the process to 100% adjudication is not only done correctly from an accounting standpoint, but compliantly.

Reach out to us to schedule a free consultation! Contact Sheila Lazarus, Business Development Manager, RCM Solutions, at sheila.lazarus@lighthouselabservices.com or by calling 517-486-4262.

Who's reviewing revenue strategy with you at this time?

Are you billing all the correct CPT codes? You’d be surprised at what you might be missing. We will review your Fee Schedule/Charge Master at no cost.

That’s right. For free.

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