Q.
Is there a limit to how much I can charge an out-of-network patient? I was told that doctors in New Jersey were being sued by Aetna for out-of-network charges.
A
There is no set fee that you are required to charge, and the patient’s contract with his or her insurance company may vary as to how much the insurance company pays. We would suggest charging your regular fee, not your discounted fee. You must charge patients their deductible and co-pays; therefore, the amount you charge the insurance company will also affect the amount charged to the patient. In fact, when you do not have a contract with the patient’s insurance company, your contract is with the patient and the amount you charge is to the patient.
The lawsuit was triggered by charges to Aetna that were far above other charges in the area, such as over $50,000 for a consult and nearly $60,000 for an ultrasound, according to articles in the lay media. These were charged to and paid by Aetna because the patients’ contract called for Aetna to pay the full amount charged, and lawsuits filed by the American Medical Association and state of New York have taken away the usual and customary benchmarks insurance companies have used in the past to determine the amount they would pay for out-of-network charges.
The concern that the docs do have a problem is based not only on the unreasonable fees. There is an argument that if the insurance company did not pay the full amount billed and the physician did not charge the patient the relative balance due based on the original charge, the potential exists that it could be proven as fraud in the legal system. Finally, in Colorado, it is a misdemeanor to charge the insurance company and write off the patient’s percent of the payment due per their contract. This type of law has been adopted in other states as well, opening up the physician to charges beyond fraud.
In other words, you can charge what you wish, but you should be realistic and reasonably consistent in your fees. This does not mean that you must have the same fee schedule for all payers, but you should have defensible charges for any person or company.
Q.
I am not getting paid for implantable testosterone pellets. What is the correct way to bill?
A
Billing for Testopel has been a real challenge, as we see quite frequently with new part B drugs. When billing for Medicare patients, the Centers for Medicare & Medicaid Services recently indicated that Testopel should be billed as follows:
J3490: Use the unlisted J code in the first line of the procedure code section (box 24), along with “one” unit and the full price to be charged.
11980: Subcutaneous hormone pellet
In the comment box (box 19), put:
a. Testopel, testosterone pellets
b. _______# of pellets
c. The National Drug Code number (43773-1001-2).
We are testing this with a number of medical directors to be sure that all are paying.
Private payers are all over the map on paying for the pellets. Some may follow Medicare rules, while others will not accept information in the comment box. For some, you would charge the unlisted code with the total number of units and the full price in box 24. Some private payers accept the “S” code (S0189), and others do not. (Never bill Medicare with the “S” code). For any payer that you’ve been successfully billing, don’t change a thing.<o:p></o:p></span></p>
Q.
I perform uroflow and a bladder ultrasound for residual on each patient at 2 to 3 weeks post-laser prostatectomy. Can I charge for those services using a –79 modifier and a different diagnosis?
A
First and foremost, it would be incorrect to place a –79 modifier on these services, since these tests are related to the results of the surgery. Recall that modifier –79 is for services unrelated to the surgery and provided during the global period.
Typically, payers will cover many diagnostic services, such as x-ray services and lab services, within the global period. Fortunately, the ultrasound for residual (51798) is actually treated like a diagnostic service code, even though it is in the surgery section. The code is designated with a global period of “XXX.” Therefore, it can be charged in the global period without a modifier.
The uroflow is assigned a global period of “000” and is treated as a service and not a diagnostic procedure. Based on the fact that the uroflow is designated as a procedure and is clearly related to the surgery, we recommend that you do not charge for this service within the global.
