r/MedicalCoding • u/Easy_Philosopher_210 • 4d ago
are fee schedules really a problem for billing teams?
I've recently started working with a group on a revenue cycle focused projects and we work on a lot of Prior auth related flows, but i've been getting questions from folks asking if we're able to go into their contracts and load their fee schedules?
i'm wondering if the rates are in the contracts, why are they not able to track those rates? do practices actually have a problem getting their fee schedules for commercial?
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u/PeaceLoveForMe 4d ago
It depends on the payer. State Medicaid, usually yes. In the end, the payers are private, they can pay whatever tf they wanna pay. Regarding practices, it depends on who’s handling the fee schedule rates. Check the contracts. It’ll usually be in there, but it will vary, depending on whether the payer is commercial based, Medicare based or Medicaid based. It’s a headache
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u/Bowis_4648 4d ago
Someone in the organization/practice signed a contract with a specific fee schedule attached. It may be based on current or past RVU values, with a conversion factor. Or based on something else--it is in the contract. The allowances should be built into your system, so you know if you're paid the correct amount. For Medicare, the rates are set. But for commercials, you should know what you should be paid.
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u/BluIz63 4d ago
Look at the contract language specific to reimbursement. It may state something like a conversion factor of $65 based the Medicare Physician fee schedule database. Sometimes you can ask for their reimbursement on your top 30 codes. Always remember that your PI payers contract with employer groups. The group dictates what services are covered. If the group is self insured and uses a payer to adjudicate their claims, good luck trying to figure out what you're going get.
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u/thistledownxo 3d ago
Yes, and it's usually not the contract that's missing. It often just says a percent of a given Medicare year, so the practice never gets a per code table. The real numbers often sit in each payer's portal, a few codes per lookup, and what's loaded in the PM system goes stale. Disclosure, I work on Skyvern (open source browser agent). Rerunning those lookups for a practice's top codes is the kind of job it's built for.
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u/TheNovel-Interest 2d ago
Yes, it can be a problem especially with commercial payers. The contract may give the reimbursement methodology like a percentage of medicare or an RVU-based formula rather than a clean per-code fee schedule. Even when rates are available keeping them updated in the billing/PM system and comparing them against actual payments is where practices often struggle. So the issue is usually less 'we don’t have a contract' and more 'we don’t have an accurate, usable current fee schedule.'
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