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Private Health Insurance in the World of Title X

Emily Kinsella, MSPHFamily Planning Administrative Consultant

Colorado Dept. of Public Health and Environment

September 20, 2012

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Sliding Fee Scale Charges versus Third Party Reimbursement

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Third Party ReimbursementAgencies should have a standard fee

schedule that they use to bill insurance, Medicaid and self-pay client

Maximizing third party revenue:Agencies can establish a “usual, customary and

reasonable” (UCR) charge for visits and procedures.

The UCR is what is charged to Medicaid and Private Insurance.

It is also what is charged to higher income clients.

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Usual and Customary ChargesDetermining Usual and Customary charges

based on the Medicare Physician Fee Schedule.

Go to Center for Medicaid and Medicare Services (CMS) website: https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspxAccept Terms

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Usual and Customary Charges

Search Criteria;Leave the first two

items as they are.Click “List of

HCPCS Codes.”Click to enter a

“Specific Locality.”

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Usual and Customary ChargesEnter CPT CodesUnder Modify,

select “All Modifiers”

Under Carrier/MAC Locality, select “0330201 North Dakota”

Hit “Submit”

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Usual and Customary Charges

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Usual and Customary Charges

Highest Usual and Customary Charge is generally around 140% of the Non-Facility Limiting ChargeNon-Facility Limiting

Charge140% of Charge

99201

$45.76 $64.06

99202

$77.95 $109.13

99203

$112.39 $157.35

99204

$171.39 $239.95

99211

$21.39 $30.21

99212

$45.76 $29.95

99213

$75.72 $106.01

99214

$111.99 $156.77

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Back to the Sliding Fee Scale

For some agencies, the 140% Charge might be close to (or less than!) their cost and they can use their sliding fee scale as is.

For others it might be more.

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Back to the Sliding Fee ScaleIf it is more, the sliding fee scale can be modified:

adding an additional column showing the Usual, Customary and Reasonable (UCR) charge which is a step up from the charges to client above 250% of the Federal Poverty Level

Clients at higher income levels (for example above 350% or 400% FPL) would also be charged this amount.

These amounts are not linked to the Title X portion of the fee scale (0%FPL to 250% FPL)

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Example Fee ScheduleExample:

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Back to the Sliding Fee ScaleThe UCR can then be increased to reflect any

increases in reimbursement rates from third party payers.However, the Title X portion does not change

unless the costs change.

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Notes About Private InsuranceWhen a contract is in place with an insurance

carrier, the terms of the contract (co-pay requirements, acceptance of reimbursement as full payment, fees set by the third party, etc.) must be followed.

If a client is in the zero pay category (less than 100% of the federal poverty level), and a co-pay is required, the client may not have money for the co-pay. In that case, the clinic can choose to waive the co-pay.

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ANY QUESTIONS?