The Importance of Finding Payer Fee Schedules

Create a Solid Foundation for Billing Practices in your Chiropractic Office

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When it comes to best billing practices in the clinic, I believe the foundation must be built before the patient enters the office. It begins before you are enrolled with a specific payer or a subsidiary plan where the payer acts as a third-party administrator. Many times, offices walk into contracts to gain new patients or just because everyone in town accepts a specific insurance plan. However, signing a contract without understanding the implications of the contracted rates can lead to financial losses for your clinic. Therefore, before you are so quick to sign on the contract line, know if network participation is profitable for your clinic.

A contracted rate is the amount an insurance payer has agreed to pay for services provided. Contracted rates vary based on services and providers. It is recommended that you have these rates on file so that you always know how much you can expect to be paid and to ensure you are collecting from the patient the amount they are responsible for based on the payer’s actual fee schedule.

When billing a payer, you may either bill your full office fee or the contracted fee with payer. Some offices feel concerned about billing the contracted rate and fear they are presenting a dual fee schedule, but remember, this is a “contracted rate” that you have agreed to. By billing the contracted rate, you are not representing a dual fee schedule. However, most offices choose to bill their full office rate, as often it is hard to manage changes with payers the moment they happen. If you prefer to bill your full rates, insurance payers will write off any amount that exceeds your contracted rates. This amount will be listed as the contractual obligation on your ERA/EOB.

Most software today can bill your full office rate but assign patient responsibility and anticipate AR on the payer’s allowable rate. Imagine meticulous ledgers, stellar AR reports you can rely on, and patient collections that create no financial concerns. It can be done, and getting your office’s individual payer and plan fee schedules is worth the time investment.

The challenge has long been getting the fee schedules from the payer. No one has time to sit on the phone for an hour to be told they can’t give them this information. What if this information is within your grasp? What if you don’t have to spend countless hours on this task to have to do it again down the road? Maybe you aren’t aware of the benefits. Perhaps you don’t know all the tricks.

For those who can’t easily find their fee schedules or the payer refuses to give you your contracted rates, there is one other practical way to get your allowable fee schedules: Watch your ERA/EOB files for services after the payer’s fee updates. As you bill for a service, change the allowable rate in your software.

Cleaner ledgers, better revenue anticipation, and confident collections at the front desk only leave the door open for growth.

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