Q: Clinic’s question - It appears that ABC health plan is now accessing the XYZ PPO network. Our ABC contract states that we should get paid at 80% of our BILLED CHARGES. XYZ PPO is taking the 80% of our billed charges (ABC discount), and then only paying 70% of the reduced amount. Is this correct, or should we be getting paid the 80% of our billed charges per our contract?

A: Your clinic should get 80% off of billed charges when you combine what the plan pays and what the patient is responsible for paying. In this case, it appears your clinic was paid correctly. If this particular's benefits are a 70/30 split, you would get 70% of the maximum allowable from the plan and 30% of the maximum allowable from the patient. For Example:

• A Provider bills: $100
• The Max Allowable by contract is 80% of billed charges, therefore $80
• The Patient's benefit plan is 70/30
• The Plan pays: $56.00
• The Patient pays: $24.00

Q: I received a letter from a third party network stating that I was part of their network and that I would be treating patients at 50% off of billed charges. I was surprised by this letter and didn’t realize that I was part of their network. What should I do?

A: Sometimes paperwork that comes across a clinic owner’s desk can be lost. PREFERRED suggests that you go through a monthly update with your office manager on all the health plans that you are currently participating in so as to not be taken off guard when you receive such letters. Regarding your recent letter, please contact PREFERRED’s Provider Relations team for assistance. Unfortunately, if you have a direct contract with this health plan and it is not contracted through PREFERRED, you may have to honor the discount.

Q: How can I access current and past Medicare rates?

A: The CMS web site provides a tool that allows providers to input codes that generates current Medicare rates. Follow the link: http://www.cms.hhs.gov/apps/pfslookup and perform these basic steps:

• Once you click on the link, review the “License for Use” document and scroll down—Click on ACCEPT
• Click START located at the bottom of the page
• For the criteria:Pick "Range of HCPC Codes"multiple codes, and/or "List of HCPC Codes"
• Next, select "Pricing Information"
• Click NEXT
• Under Carrier Option, click on Specific Locality and select Default Fields
• Click NEXT
• Enter your code range (97001 - 97799) and select All Modifiers in the drop down menu
• Click SUBMIT