SETTING THE FEES FOR YOUR MEDICAL PRACTICE

This is probably the most prevailent system we have seen used, in spite of the fact that it is flawed. Many medical office staff have disclosed that they had called other offices in their area of the same specialty, and pretended to be a possible new patient. They would ask what the practice charged for a new patient office visit, perhaps describe a few symptoms and then they would hang up. They would would then report to the doctor that Dr. So&So charged so much for a new patient visit. What they didn't realize is that they had basically NO INFORMATION. They didn't know if the other office had quoted them a fee for code 99212 or 99213 or 99214 or even 99215. The information they had was basically useless.

Using Medicare Fees to Determine Private Fees::

Probably, the second most common method we've seen physician practices use to determine their fees is to take the Medicare Approved Amount or Medicare Limiting Charge amount and multiply it by a certain amount to derive a fee for commerical carriers. While this practice is common, the multiplier used is not. We've seen it range from as low as 20% above the Medicare amount to double the Medicare amount. The problem with this approach is that Medicare does not always pay fairly and use the same rules for globabl surgery, multiple procedures, modifiers, etc... as commercial carriers. For instance, commercial carriers use the astericks in the CPT manual to determine whether a procedure is allowed to be charged with an office visit or not and Medicare does not. We do not recommend this method either.

We suggest you find an honest, reputable and experienced reimbursement consultant familiar with the fees being charged by physicians in the area you plan to locate in. One of the easiest ways of doing this is to contact other physicians in the area you plan to practice and ask them what consultants they recommend. Also, when considering a consultant, we suggest you find one that GUARANTEES your satisfaction and is willing to give you an extensive list of other physicians or hospitals they have worked with. After receiving this list, we suggest you go a step further and actually CALL or speak to some of the physicians. Be careful when doing this that you don't just talk to the office staff, as it may be that the consultant has previously pointed out problems with the staff and some may have taken it personally.

You may decide to call your state medical association and ask for a referral to a consultant, but beware of a practice by SOME state associations..... Some associations receive kickbacks or "referral fees" from consultants, so instead of referring whoever is best for the members, they refer to whomever is willing to give the association a "referral fee". As an example, we contacted the TMA, shortly after opening our consulting practice, and asked how we could receive referrals from them to their members. We received a letter on the Texas Medical Association letterhead that asked for "a computation of the royalties the TMA would receive". After verifying this was their policy through their legal department, we have never contacted them again. A good consultant does not have to bribe or "buy" referrals if they do a good job. Not all associations do this though. Another example would be the Texas Osteopathic Medical Association. The TOMA has never asked us for referral fees or any kind of kickback and we receive all of their referrals and endorsements. The reason they do so is because it helps their members, helps their association and we greatly appreciate that. It is obvious that the TOMA does their best to help their members. We cannot say the same for the TMA. We have experienced the same kind of response from several specialty associations at the same time, while not all. Another association that has never asked us for "referral fees" is the American College of Family Physicians. We have worked extensively with them and they have always operated in the same manner as the TOMA, which we greatly appreciate.

If you do pick just one fee schedule range, we would probably recommend PMIC, which can be reached by calling 1 800 633 7467. No- we receive no referral fees from PMIC, but their fee schedule does give a range of average fees for each procedure. Of course, we use a complex formula using Lotus 123 to arrive at our recommended fees for our clients, but if you are stuck and cannot arrive at a particular fee for a specific service, you may want to check these out.

We get many requests to help physicians set up fees in different parts of this country. We now work with physicians throughout the U.S. If you are in a specialty that we do not have extensive experience in, we may feel the need to refer you to a consultant that will work in your area for your specialty. Drop us an email note and we can probably recommend someone that has the same ethical standards as ourselves, that you may wish to contact.