Can a medical provider bill different amounts to different insurance companies?

Question

I previously worked for a doctors office who billed in a way that I thought was wrong. The billing staff would bill Medicare 1 amount for an office visit (say $93.00 for a level 2 E&M) and then would only bill $75.00 to a group insurance, and would bill workers comp $105 for the exact same service. Can a medical provider legally do this? It has always been my understanding that you have to bill all insurance companies the same amount no matter who they are and you have to adjust off the difference of the contracted rate/payment. If this is illegale what would the penalties be (Texas) for a provider doing this? I recently quit working for this medical practice, but I just can't get over the thought that they are doing this totally wrong and could get into a lot of trouble. Apparently though, they have been doing this since they opened back 1995. Any REAL input on this, say a certified medical biller or medical office manager's input would be nice.

Answer 1

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Answer 2

That sounds strange to me too.

I work for a large hospital system and in the past have worked for a physical therapy group.  We always had a standard set of fees that was billed to all payors.

Obviously we were reimbursed differently by each payor depending on the contract allowance, but our actual billed charge was the same for each service no matter who the payor.

Like you, I was under the impression that it was part of the legal billing requirements.  However, I am not familiar with the laws of Texas.

I would think that either Medicare or any of the insurance companies the office is contracted with would be interested in knowing that information.  They may be obligated by contract with those individual groups to bill the same fees as they would to all payors.  (So, regardless of whether the behavior was legal/illegal according to state law, it could still be in violation of the contracts.)

Answer 3

Medical providers have contracts with each insurance carrier.  The contract sets forth the amounts reimbursable for each type of treatment or procedure.  The amounts differ in each contract.  It is probable that your former employer was doing everything correctly.

Answer 4

What happens is that providers have contracts with networks on how much they will pay for services. Usually, self pay people get taken to the cleaners.