Better look closely at your billing. Why? We found a large commercial payer which is not paying according to contract.
Why would this matter if you are a professional provider billing under the CMS physician fee schedule? Well, take a look at the prostate biopsy code G0416. Per the carrier contract, the G0416 is to be paid at 125% of the insurance fee schedule; however, the carrier has been recognizing this G0416 under the contracted amount for “all other HCPCS codes,” which represents 70% of Medicare.
Is this costing you money? How are you going to handle this loss and renegotiate a fair payment?
According to the contract:
|G0416-G0418||125% of Carrier’s designated fee schedule|
|All other HCPCS codes||100% of Carrier’s designated fee schedule|