By now, it’s been over six months since the Billed Amount “BA” bombshell regarding Geico has been wide-spread throughout the PIP community. As a provider or PIP attorney, you are likely seeing that Geico is doing their best to pay correctly once the new bills are received, or pay correctly once they receive a demand letter, or continue fighting/appealing if the case is in litigation. This article addresses how altering a provider’s fee schedule may produce significantly higher reimbursements.
Geico’s policy language states in part that a “charge submitted by a provider, for an amount less than the amount allowed above, shall be paid in the amount of the charge submitted.”
What this means is that if the 200% Medicare Part B rate is $349.14 (like it is for the CPT Code 99204 for dates of service 03/01/18 – 02/28/19 in the Fort Lauderdale region of Florida) and the provider is charging LESS than $349.14, then Geico is reimbursing the entire amount of the charge, not reducing and paying only 80%.
So if a provider charges $349.00 for CPT Code 99204 in the Fort Lauderdale (includes the following counties: Broward, Collier, Indian River, Lee, Martin, Palm Beach, and St. Lucie), they will be paid $349.00 by Geico. If they charge $350.00 for this code (only $1 more), they will get 80% of $349.14, which is $279.31. By charging UNDER the fee schedule, a provider can receive $70.69 more from Geico for a 99204.
SHOULD I CHANGE MY CHARGES?
You’ll have to decide for yourself, but consider the following example (using CPT Code 99204 for Fort Lauderdale region for Medicare year 2018).
Provider “A” charges $400.00
Provider “B” charges $350.00
Provider “C” charges $349.00
Provider “D” charges $300.00
We’ll compare two different payors for this example: 1) Geico, and 2) all other PIP insurers. Below is a chart of expected compensation for PIP benefits.
|Geico||All other insurers|
1 – because the charge is higher than the allowable amount and will be paid at 80% of 200% of Medicare Part B
2 – because the charge is less than the allowable amount, it will be paid at its full charge, per Geico policy
3 – because the charge is less than the allowable amount, it is being paid at 80% of the billed amount, per statute
In the example above, provider C surely has the highest reimbursement because they charge just under the fee schedule.
HOW LONG CAN THIS LAST?
The first question I asked myself when writing this was what if this is only for a few weeks, or months? Is it worth it for a provider to change their fee schedule for what could be maybe a few weeks?
The answer is no one actually knows other than the people in charge of writing Geico’s policy. What I do know is that when I worked on the defense side and State Farm switched to their 9810A policy, it took a long time for them to implement it, change their language, and start issuing new policies. So even if Geico decided to change their policy starting January, 2019, that means all policies issued over the next three months would still have this old language, and they would be in effect for six months once issued. Again, this is something each provider would have to consider with regards what is best for them.
Therefore, if Geico instituted a change that erased this issue for all cases, there’s a very real potential that it is still available for months and months. Take a conservative estimate of 6 more months. If Provider C is getting 2 new Geico patients a week, for the next 26 weeks, that is 52 more times to bill 99204 and recover $70.69 more than Providers A and B, who are billing higher than the fee schedule. That’s $3,675.88 more coming to a Provider C over the next six months. (Hopefully,) Geico may take even longer to change their policy; and this is just one CPT Code that isn’t billed every visit – imagine if all charges, especially for therapy codes was similarly changed.
IF I BILL LESS THAN FEE SCHEDULE, IT WILL REDUCE WHAT I GET FROM ALL OTHER INSURERS
This is true, and something that should be considered when deciding whether or not to alter your fee schedules as a provider. I believe Geico is the most common insurer in Florida, so let’s assume that 30% of a provider’s PIP patients have Geico and 70% have other insurers. As a provider, you won’t want to miss out on the other insurers by charging too much less than the fee schedule because you are leaving money on the table.
That is why Provider D is in the example above. If there are 100 patients, and 30 have Geico and the rest have other insurers, then Provider D is going to make $25,800 [(30 x $300) + (70 x $240)]. Provider D is making less than Providers A and B, who are making $27,931.00 for 100 patients. But Provider C is still way ahead by making $30,014.00 [(30 x $349) + (70 x $279.20)].
The takeaway is this – the closer to the fee schedule you are when charging less than it, the less you will lose from the insurers other than Geico. So Provider C is going to lose out on 11 cents from all other providers, but make $70.69 more Geico by charging the nearest whole dollar below the fee schedule.
CAN I CHARGE THE FEE SCHEDULE EXACTLY AND ACHIEVE A WIN/WIN?
It’s not that easy. I have spoken to PIP counsel for Geico and one of the issues they are fighting is that their policy language says “an amount less than the amount allowed.” This means that if the charge is exactly $349.14, they will claim they can still pay 80% of it. My opinion is it’s not worth it to try and be too cute with the charge in case it comes back to bite you. Provider C is giving up $0.11 from all other providers to get $70.69 extra from Geico every time 99204 is billed.
This can be a very confusing topic due to the different CPT Codes, percentages, different insurers, etc.
At Lawlor & Associates, we would be happy to consult with any provider and discuss their fee schedule and how the topics of this article may impact their practice. We would love the opportunity to send out demand letters on old Geico files going back five years. As always, if you have any questions about this topic, please feel free to contact me so we can discuss it further.