What is a Fee Schedule?
The fee schedule is the breakdown of what the insurance company will pay for specific services, otherwise known as the contracted rate. It is sometimes sent as part of the contract with the insurance company, however it could also be a separate document. It will likely be a table that includes a list of CPT codes, and the dollar value that the insurance company is agreeing to pay for that particular code, sometimes broken down by level or type of license. You will have a different fee schedule for every insurance company that you are credentialed with.
Fee schedules are proprietary information, and insurance companies will often be very strict about giving this document out to anyone other than the provider whose name is on the contract. Fee schedules are not to be shared among providers, and when you are sharing the fee information with a patient, avoid sharing the entire fee schedule. Tailor the information to your patient and only share the relevant CPT codes and associated costs to the patient’s treatment.
If you are missing your fee schedule, you can request this from the insurance company similar to how you would request a contract. In fact, if you are also missing your contract we would recommend requesting both of these documents from the insurance company. Fee schedules will typically only be released to contracted providers, and if you are not yet credentialed with an insurance company you will most likely not be able to see their fee schedule. This is dependent on the insurance company policy. As a credentialed provider, it is possible that your fee schedule may be accessible through an online portal, and you could check there before calling the insurance company to request the fee schedule.
Knowing your fee schedule is critical to running a successful practice, especially with the recent implementation of the No Surprises Act. Your fee schedule along with eligibility checks are the greatest tools in providing good faith estimates to your patients. For more information on good faith estimates and compliance with the new law, check out our article on the No Surprises Act.
It is extremely helpful for you to have a copy of your fee schedule so that you can verify that you are getting paid what you should be getting paid by the insurance company according to your contract. Knowing your fee schedule is also helpful in submitting claims for the correct amounts to begin with, and in providing information for benefit checks. You will also need to know your fee schedule in order to determine the amount a patient owes for a coinsurance, as the amount that they would owe is a calculation of the percentage of the contracted rate.
As a practice owner, you can use the information on your fee schedule to project revenue. This is a much more accurate method than using an aging report, as the aging reports typically show the full cash value of a session rather than the expected contracted amount from insurance. You can use the numbers on a fee schedule to create projections of income in your practice, or you can set goals for yourself on the average number of sessions you would need to complete in a week to meet a specific level of income.
Have copies of your contracts and fee schedules and still feel lost? It may be time to hire a billing company. Practice Solutions billers are highly skilled in interpreting fee schedules in order to keep your billing neat and compliant. As a client of Practice Solutions, your biller would be able to answer any specific questions you have on insurance billing and how your fee schedule fits in! Contact us today on our website to learn more!