Out-of-network charges: What are the rules?

May 1, 2011

There is no set fee that you are required to charge, and the patient's contract with his or her insurance company may vary as to how much the insurance company pays.

Q. Is there a limit to how much I can charge an out-of-network patient? I was told that doctors in New Jersey were being sued by Aetna for out-of-network charges.

In other words, you can charge what you wish, but you should be realistic and reasonably consistent in your fees. This does not mean that you must have the same fee schedule for all payers, but you should have defensible charges for any person or company.

Q. I am not getting paid for implantable testosterone pellets (Testopel). What is the correct way to bill?

A. Billing for Testopel has been a real challenge, as we see quite frequently with new part B drugs.

When billing for Medicare patients, the Centers for Medicare & Medicaid Services recently indicated that Testopel should be billed as follows:

We are testing this with a number of medical directors to be sure that all are paying.

Private payers are all over the map on paying for the pellets. Some may follow Medicare rules, while others will not accept information in the comment box. For some, you would charge the unlisted code with the total number of units and the full price in box 24. Some private payers accept the "S" code (S0189), and others do not. (Never bill Medicare with the "S" code). For any payer that you've been successfully billing, don't change a thing.