Provider Reimbursement

Written by Norene Anderson
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Provider reimbursement is directly related to the values associated with CPT codes. The relative value established for each code is the basis for insurance providers determining the amount of reimbursement for services rendered. Each provider interprets the data according to guidelines specific to the carrier. Medicare and managed care organizations are similar in reimbursement strategies.

The crucial point in obtaining the most in provider reimbursement is to have all claims filed with the appropriate codes. The CPT code, ICD-9 code, HCPCS, and NDC must correlate to substantiate the proper billing. If the codes do not support each other for diagnosis, procedures, and treatment modalities, the claim will either be denied or put on hold until clarification can be obtained. This can tie up a claim for months.

Provider Reimbursement Enhancement

Codes are designed to be very specific. Each one has a direct impact on the amount of provider reimbursement that will be paid. Some codes include bundled charges while others are individual item charges. Some carriers allow individual item charges and others only pay a bundled price for reimbursement. It is vital to know how the carrier requires the charges to be documented in order to receive proper payment.

There are companies specially trained to file claims with the codes to maximize the reimbursement to the provider. These are often recipients of outsourced medical coding and billing responsibilities. This alleviates the hospital or physician from the responsibility of providing physical space for more employees and from the financial burden of supplying the necessary equipment to provide the service.


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