Emily Kinsella, MSPH Family Planning Administrative Consultant Colorado Dept. of Public Health and Environment September 20,

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Third Party Reimbursement Agencies should have a standard fee schedule that they use to bill insurance, Medicaid and self-pay client Maximizing third party revenue: Agencies can establish a “usual, customary and reasonable” (UCR) charge for visits and procedures. The UCR is what is charged to Medicaid and Private Insurance. It is also what is charged to higher income clients. 3

Usual and Customary Charges Determining Usual and Customary charges based on the Medicare Physician Fee Schedule. Go to Center for Medicaid and Medicare Services (CMS) website: fee-schedule/search/search-criteria.aspxhttps:// fee-schedule/search/search-criteria.aspx Accept Terms 4

Usual and Customary Charges Search Criteria; Leave the first two items as they are. Click “List of HCPCS Codes.” Click to enter a “Specific Locality.” 5

Usual and Customary Charges Enter CPT Codes Under Modify, select “All Modifiers” Under Carrier/MAC Locality, select “ North Dakota” Hit “Submit” 6

Usual and Customary Charges 7

8 Highest Usual and Customary Charge is generally around 140% of the Non-Facility Limiting Charge Non-Facility Limiting Charge140% of Charge 99201$45.76 $ $77.95$ $112.39$ $171.39$ $21.39$ $45.76$ $75.72$ $111.99$156.77

Back to the Sliding Fee Scale For some agencies, the 140% Charge might be close to (or less than!) their cost and they can use their sliding fee scale as is. For others it might be more. 9

Back to the Sliding Fee Scale If it is more, the sliding fee scale can be modified: adding an additional column showing the Usual, Customary and Reasonable (UCR) charge which is a step up from the charges to client above 250% of the Federal Poverty Level Clients at higher income levels (for example above 350% or 400% FPL) would also be charged this amount. These amounts are not linked to the Title X portion of the fee scale (0%FPL to 250% FPL) 10

Example Fee Schedule 11 Example:

Back to the Sliding Fee Scale The UCR can then be increased to reflect any increases in reimbursement rates from third party payers. However, the Title X portion does not change unless the costs change. 12

Notes About Private Insurance When a contract is in place with an insurance carrier, the terms of the contract (co-pay requirements, acceptance of reimbursement as full payment, fees set by the third party, etc.) must be followed. If a client is in the zero pay category (less than 100% of the federal poverty level), and a co-pay is required, the client may not have money for the co-pay. In that case, the clinic can choose to waive the co-pay. 13

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