Health Information Management

Strive to bill all payers the same

APCs Insider, July 28, 2006

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Strive to bill all payers the same

QUESTION: How do you capture department charges for services that are payable by commercial payers, managed care, etc. but that are not compliant with Medicare regulations? For example, if Medicare considers an item or service bundled or packaged, how do you set that up in the chargemaster for other payers?

ANSWER: The answer to this question usually has more to do with your information system than it does anything else. Consider the following advice:

It is not advisable to have multiple CDMs, i.e., a different CDM for each payer. While it is true that some payers will pay for items or services that Medicare will not, there is often another method for capturing this revenue. Ask yourself these questions:

  • Does this item have to be billed separately?
  • Is the payer looking for a specific CPT/HCPCS code on the claim?
  • Can this item/service be bundled with another charge?

In short, strive to bill all payers the same (using the word "bill" means that we are charging all patients the same, but the billing format may be unique to a payer). It is too much of a compliance risk to bill them differently.

In those rare instances where you do have to bill payers differently, obtain the instruction in writing from the payer. This may be difficult or time-consuming, but if in future years you are questioned about your billing practices you'll need documentation. A denied claim is not sufficient documentation: Remember payers have mistakes in their computer system too.

If the required change for a payer is a different application of a CPT/HCPCS code, then most providers make that change in a claims dictionary. A claims dictionary is a file that applies unique billing requirements for each payer based upon an insurance code. Understand that this method is 100% reliant upon the correct insurance code. You can either change the Medicare codes for a specific payer or change your existing codes to be Medicare compliant. Some facilities use "point off" codes. These are charges that are billed for all non-Medicare payers.

In some small departments, you may find multiple sets of charges based on the payer. Staff assign the codes based upon the patient's payer, but remember payer information often changes. Another option for payers with a small volume is to fail all their claims in the business office and manually make the change.

Before making any changes or adopting an approach, we strongly recommend that you consider your options with the compliance and legal departments and possibly seek external legal council. All of these options carry great compliance risks.



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