Many of our providers will ask us what their contracted rate is for each insurance company that they’re in network with, or working with out of network.

This is an important but unfortunately disappointing fact to reveal:  we cannot know the exact amount of a reimbursement until that reimbursement has been made, checks have been issued, and EOBs have been sent out.

It is not possible for you or a billing service to obtain that information on a routine eligibility and benefits verification call.  As you may have noticed, whenever you do a call to check eligibility and benefits, there is always a prompt stating that “This quote is not a guarantee of payment, benefits will be decided at the time of adjudicating a claim.”

Well I’m In Network!

Tough luck.  The only “company” that is reliably going to let you know the exact and consistent amount of reimbursement is Medicare, our friends in the United States Government!  Who said they aren’t organized.

Medicare is actually one of the best and most consistent insurance organizations we work with nationally because of it’s simplicity, believe it or not.  Yes, you might not get reimbursed for as much, but there are often less problems (when you know what you’re doing) and less variability than other private market insurance companies, or Medicaid plans.

Your in-network contracted rate will be steady, but you still will not be told your contracted rate during an eligibility and benefits verification phone call.

Dang, I’m Out Of Network!

Then definitely don’t expect to receive the exact same amounts across patient’s over time.  Even if you use the same CPT code serving the same geographic region, out of network reimbursement rates often vary month by month.

So if you’re billing as an out of network provider, you’re truly at the mercy of what that insurance company deems your eligible to receive at the date the claim is processed.

Fortunately, out of network providers can be reimbursed for higher than an in-network contracted rate.  Unfortunately, fewer patient’s want to use out of network coverage because it’s almost always more money out of their pocket.

Why Don’t Insurance Companies Let You Know?

Coverage can change at any moment and insurance companies are trying to pay their providers as little as possible, while simultaneously covering as many benefits and medical services as they can.

They are in the business of getting the lowest rate for medical and mental health services as possible, which is why doctors and providers despise them, but is why consumers love them — they reduce an $18,000 shoulder surgery to $2000 for the patient, negotiating a lower rate to pay the surgeon (points to huge scar on my shoulder).

As such, they are going to opt to pay you the least amount they can, which means their rates will change over time, if you’re out of network.

If you’re in network, you’re in luck!  You have a contracted rate, a set fee you’re eligible to be paid no matter what.  It’s literally decided in your contract.  This is a big benefit of being in-network with an insurance panel.

How Do I  Find Out My Contracted Rate?

You can review your physical contract with the insurance company in question, which may or may not list the rates for the CPT codes you’ll be using.

But the best way is to file claims and notice the contracted rate or allowed amount on the EOBs you receive back.  This is your contracted rate and the number you can expect to be paid for each session of that CPT code.

Pro Tip:  If you are to receive a co-insurance payment from the patient, you would take your contracted rate and multiply it by the co-insurance amount to get the patient’s responsibility.  So if you’re contracted rate is $100 and they have a 20% coinsurnace, you collect $20 after EOBs are issued (co-insurance is to be collected after claims are processed, not before).  Or if your contracted rate is $80 with a 20% coinsurance, you’d collect $16.

Once you note your contracted rate for each CPT code, as rates vary per CPT code, you can then make sure that each payment you’re eligible to receive does equal that amount.   If your payment is under your contracted rate, that insurance company is breaking their contract with you and you can sue them, or more realistically call up and complain until they pay you the right amount.

Conclusion

Your contracted rate is steady when you’re an in-network provider.  The best way to find out the exact amount per CPT code is to file claims and check EOB information to see what’s listed.

If you’re out of network, your rate per CPT code, per patient, per month may vary.  This is a downside to being an out of network provider.

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