Setting an appropriate fee schedule is crucial for the financial health of your chiropractic practice.
A well-structured fee schedule ensures you are adequately reimbursed for your services while maintaining compliance with insurance regulations. One of the best starting points for establishing your fee schedule is the Medicare Physician Fee Schedule (MPFS). The MPFS offers a comprehensive benchmark for reimbursement rates, which can be adapted for use with other payers. This article presents the steps to effectively establish your fee schedule using the MPFS and provides guidance on adjusting these rates for other third-party payers.
Step-by-step guide to using the Medicare Physician Fee Schedule
- Access the MPFS
To begin, visit the MPFS lookup tool at https://www.cms.gov/medicare/physician-fee-schedule/search. This tool is designed to help healthcare providers determine the reimbursement rates for various services.
- Select the appropriate year
From the drop-down menu, select the appropriate year. It is essential to choose the current year to ensure you are working with the latest reimbursement rates.
- Choose the type of information
Next, select “pricing information” from the “type of information” drop-down menu. This will provide you the detailed pricing data for specific CPT/HCPCS codes.
- Enter the CPT/HCPCS code
Enter the CPT/HCPCS code you would like to look up. For instance, if you are looking up the code for therapeutic exercises, enter 97110. Each code corresponds to a specific service or procedure you offer in your practice.
- Select your Medicare administrative contractor (MAC)
Select “specific locality” from the MAC option drop-down menu and enter the location of your practice, for example, Miami. This ensures you receive the reimbursement rates applicable to your geographic region.
- Retrieve the fees
Click “search fees” and a table of reimbursement options will be generated below. The table will include various columns, including “non-facility price” and “non-facility limiting charge.”
- Understand the reimbursement columns
Non-facility price: If you are a participating Medicare provider, this is your fee. Non-facility refers to a private practice setting, not a hospital.
Non-facility limiting charge: If you are a non-participating Medicare provider, this is your fee, which is 115% of the non-facility price.
By following these steps, you can quickly check the codes and fees for all the services you provide in your practice.
Adjust your fee schedule for other third-party payers
Once you have established your Medicare fee schedule, you can adjust it for other third-party payers. It is important to recognize private insurance companies often pay different rates compared to Medicare.
Understand private insurance reimbursement
For physician services, private insurance typically pays an average of 143% of Medicare rates. This can range from 118% to 179% of Medicare rates across different studies. A good rule of thumb is to bill 150% of the Medicare fee. However, it is crucial to verify this with each insurance company, as coverage amounts can vary.
Check with insurance companies
Many private insurance companies list the percentage of the Medicare fee schedule they pay on their websites. It is important to check these sources to confirm the correct fee schedule for each insurance plan. This ensures your fees are in line with what each payer reimburses and prevents discrepancies.
Annual review and adjustment
Medicare reimbursement rates often fluctuate on an annual basis. Therefore, it is important to perform this fee schedule review at the beginning of each new year. This ensures your practice remains financially viable and compliant with current reimbursement standards.
The importance of regular adjustments
I’ve found many DCs haven’t adjusted their fees for years. This can result in undercharging for services and not keeping up with the cost of providing the services you deliver. Regularly updating your fee schedule ensures your practice remains profitable and capable of delivering high-quality care.
Practical tips for establishing your fee schedule
Stay informed. Stay informed about changes in Medicare and private insurance reimbursement rates. Subscribe to industry newsletters and updates from the Centers for Medicare and Medicaid Services (CMS) and private insurers.
Document your fee schedule. Keep detailed records of your fee schedule and any changes you make. This documentation is crucial for audits and ensuring transparency in your billing practices.
Communicate with patients. Clearly communicate your fee schedule to patients. Transparency in pricing builds trust and helps patients understand their financial responsibilities.
Train your staff. Ensure your staff is well-trained in understanding and implementing your fee schedule. They should be able to answer patient questions and handle billing efficiently.
Seek professional advice. Consider consulting with a coding professional or practice management expert to ensure your fee schedule is optimized for your practice’s financial health.
Consider regional variations. Understand that reimbursement rates can vary significantly by region. If your practice operates in multiple locations, adjust your fee schedules to reflect the local economic conditions and cost of living.
Use technology. Use practice management software to keep track of your fee schedules, monitor reimbursements and generate reports. This can streamline the process and reduce the likelihood of errors.
Benchmark against peers. Compare your fee schedule with those of other DCs in your region. This can provide valuable insights and ensure your rates are competitive yet fair.
Patient feedback. Gather feedback from your patients about your fees. Understanding their perspectives can help you make adjustments that are acceptable to your patient base while ensuring you meet your financial goals.
Adjust for overhead costs. Review your practice’s overhead costs regularly and factor these into your fee schedule. This includes rent, utilities, salaries and equipment. By ensuring your fees cover these expenses, you maintain a sustainable business model.
Final thoughts
Establishing your fee schedule using the Medicare Physician Fee Schedule as a benchmark is a smart strategy for ensuring fair and accurate reimbursement for your services. By regularly reviewing and adjusting your fees, you can keep up with changes in the healthcare landscape and maintain the financial health of your practice. Remember, a well-structured fee schedule not only supports your practice’s profitability but also ensures you can continue to provide high-quality care to your patients. Regular updates and adjustments based on comprehensive data and feedback will keep your practice thriving in an ever-evolving healthcare environment.
MARK SANNA, DC, ACRB LEVEL II, FICC, is the CEO of Breakthrough Coaching. He is a Board member of the Foundation for Chiropractic Progress, a member of the Chiropractic Summit and a member of the Chiropractic Future Strategic Plan Leadership Committee. To learn more, visit mybreakthrough.com. He is the author of Cracking the Code: Marketing Chiropractic—How Chiropractors Align Spines and Minds, available on Amazon.com.
