Listed Lactation Rates and Percentage Payments Are Different
Read the listed rates before applying a percentage
In lactation contracting, the percentage provision often matters because a service has no listed rate. A contract can list fixed dollar amounts for certain codes and use a percentage formula for codes outside that schedule. Reading only the percentage can give a practice the wrong picture of what its visits will pay.
Start with the actual code. If the applicable schedule lists a fixed rate for that service, use that rate when evaluating the agreement. Do not apply the unlisted-code percentage to a service already priced in the schedule. Review the contract's definitions and any setting or product distinctions.
Here, unlisted means absent from the applicable payment schedule. That is different from selecting a CPT or HCPCS code whose descriptor identifies an unlisted procedure. A missing fee does not change which code accurately describes the care.
A percentage of billed charges needs a billed amount
When the contract prices an otherwise unlisted service at a percentage of billed charges, the practice's submitted charge is the starting point. A hypothetical 60 percent of a $300 charge is $180. The same percentage of a $200 charge is $120, before any further applicable adjustments.
That example is payment math, not a quoted payer rate. Read the provision to confirm which services it reaches, whether another pricing rule takes priority, and whether limits apply. Aetna's fee schedule resource describes code-level allowed amounts; it does not establish the terms of another practice's agreement. [1]
Keep your charge schedule consistent and supportable. Choose the code that describes the documented service rather than changing codes to reach a more favorable payment provision.
Separate out of network payment from a contracted rate
Out-of-network lactation claims can also pay a percentage of what the practice bills. Where that method applies, compare payment with the submitted charge. Do not confuse that calculation with a plan paying a percentage of a separately determined allowed amount.
The plan documents matter. UnitedHealthOne describes several out-of-network pricing methods, including reference benchmarks and negotiated rates. A billed-charge percentage should not be assumed for every plan. [2]
For each remittance, identify the billed charge, pricing method, allowed amount, plan payment, and patient responsibility. A percentage used to price the service and a patient's coinsurance percentage answer different questions.
At Sunshyn, the useful question is what this code pays under this agreement or benefit. Check the listed rate first, then the applicable percentage provision. Compare actual claims with those terms before judging whether the payment is correct.
Comments