I know that insurance carriers have pre-determined rates for each CPT code. When submitting a claim, do I set the amount based on a fee that I have decided upon, or do I submit the claim based on the rate each payer has set?
When you submit a claim, the amount you charge should not be based on how much the insurance company actually pays for that service, but a rate that you set that is billed to all carriers or your rate for that service. Be sure that this rate is high enough to allow for any increases in any of the payers' allowable amount for any of the services you bill for.
The insurance company will not pay the entire amount you charge them.
For example, for service A, you charge $100.00, the payer's set rate for that service is $70.00 and the patient's co-pay is $10.00. The explanation of benefits that you and your patient receive will show some variation of the following:
|Billed Amount||Allowable Amount||Patient Responsibility||Amount Paid||Adjustment||Remark|
Remark 45: Amount billed is over contracted rate.