The goal of this article is to help you understand the components of a fee schedule as well as help make sure that the data our team is receiving is sufficient to support your Rivet experience.
What is a fee schedule?
Kinds of rate
Uploading fee schedules
Common payer fee schedules
1. What is a fee schedule?
A fee schedule is a term we use to refer to the contractually negotiated reimbursement rates between an insurance carrier and a provider. Typically these are structured with CPT/HCPC codes and have the contracted price for each of these CPT codes.
Example:
2. What rates are found in a fee schedule?
There are three key rates that are present in a fee schedule:
Professional - Non Facility
This is the rate if you were to bill a procedure out from your clinic with place of service '11'
Professional - Facility
This is the rate if you were to bill a procedure out when services are rendered elsewhere (such as an Outpatient Hospital - place of service '22', or an Ambulatory Surgery Center - place of service '24')
ASC - Technical
This is the rate if you were to bill the facility charge for an Ambulatory Surgery Center - place of service '24' if billed on a 1500 or UB type '83' of billed on a UB-04
How do I know if a rate applies to me?
Question: Do you bill services in your clinic using place of service 11?
Answer: You'll need professional - non facility
Question: Do you ever render services at a hospital, ASC, or other facility? (Surgeon fees)
Answer: You'll need professional - facility
Question: Do you bill out for the operating room/facility charges for an ASC? (Operating room)
Answer: You'll need ASC - technical
3. Uploading fee schedules into Rivet
In order for each fee schedule to be built correctly in Rivet, each fee schedule file should contain the following:
If based on Medicare:
If based on Medicare rates, please provide the percentage of CMS each code category is based on. Rivet has built-in CMS rates for each year and locality, which update automatically and will be most accurate to use.
If not based on Medicare:
All place of service rate types, applicable to your clinic (e.g., Professional Facility, Non-Facility, and/or ASC)
Any referenced fee schedules from your contracts. For example, an Aetna contract will often make reference to an “Aetna Market Fee Schedule.” If this is the case for any contracts you are uploading, please make sure to also upload the referenced fee schedule, otherwise we will not be able to complete the fee schedule for that payer.
An effective date. We recommend that each fee schedule be the most up-to-date you have, preferably effective within the past few years.
Insurance product name. If you have multiple plans for the same insurance carrier, please specify the name of the plan in the file so that we can upload it in the right place.
All billed codes. We recommend that each fee schedule contains all codes that you bill. This will ensure that the Rivet products will function properly.
If there is any other information you think we would need to know when building your fee schedules, please include it in the file description box when uploading a file.
4. Common payer fee schedules
Many major payers follow similar structures for their contracts. If you are contracted with any of the following payers, please make sure that you send all relevant information.
Aetna
Almost every Aetna fee schedule will be based, at least in part, on the Aetna Market Fee Schedule. This is a separate file that will also need to be provided to Rivet. If you do not have the Aetna Market Fee Schedule, it will need to be requested from your Aetna provider representative. See this help article for more details on how to request the Aetna Market Fee Schedule.
The Aetna Market Fee Schedule will likely look something like this:
BCBS
While each BCBS contract will differ by state, it will often include their own proprietary BCBS fee schedule. Your BCBS contract may something like the following example. If so, we will need the appropriate BCBS fee schedule, which will be a separate file.
Cigna
Cigna contracts almost always reference the Cigna RBRVS and Cigna Standard Fee Schedule. These fee schedules are determined by Cigna, and therefore are separate files that Rivet will need to complete the Cigna fee schedules.
All other payers
If any contract states a proprietary fee schedule that isn’t based on Medicare, then Rivet will need that fee schedule.
If you have any additional questions about the fee schedules feel free to chat in or email at success@rivethealth.com.
Suggested Next Article - Creating a Fee Schedule with the new Builder