Finding and Maximum Reimbursable Charges for particular bill codes.?

Question

I used an out-of-network provider for behavioral therapy services, and got socked with an "Amount Exceeds Maximum Reimbursable Charge" issue.

According to my contract, the maximum reimbursable charge is what a doctor in the 90th percentile charges for similar services. Or, in english, if the doctor is in the 10% fee-charges, it's exceeded.

In my case, it made no sense. The invoice stated 1 1/2 hours of therapy services, and the "Maximum Reimbursable Charge" was $65.00. I don't think that's the 90th percentile. You can't hire a handyman or mechanic for that, I can't imagine a certified behavioral therapist is cheaper. In short, I think they are lying.

Is there a way to find out what the "maximum reimbursable charge" is for a given bill code? How do the insurance companies know what is the 90th percentile for fees for any given bill code? What research can I do to refute their amount?

Answer 1

Actually, that amount doesn't sound completely out of line.  Behavioral health providers don't tend to get very high reimbursement.

(h**l, I know a few insurers that only pay $50 per visit per day for physical therapy...no matter how long your visit was and what treatments you had.)

But to answer your question...it depends on what data source your insurer decides to use.  Many use data from HIAA.  (Health Insurance Association of America)  But its not data that you're going to be able to get for free.

You can try looking to see what Medicare would reimburse for the code...that's public information that can be found on the Medicare website.  (Note - if you don't know where to look, it can be difficult to find...post the CPT code and one of us can help you find it.)