Albany Eye Associates

Thank you for bringing this matter to our attentionPlease see our response below: Medical billing is unlike billing for other lines of business Medical billing uses a series of codes (CPT codes) and each code is assigned a RVU (relative value unit)These codes describe the services performed A is a new patient visit CPT where is an established patient visit CPT There is a formula (conversion factor) that is multiplied by the RVU for the code and that becomes the allowable payment from the insurance carrier These conversion factors and RVUs are based on CMS (Centers for [redacted] and [redacted] ) policy Every insurance company uses some variation of the CMS conversion factor They may base their allowed payments on times the [redacted] allowable fee In very basic terms as an example: a CPT code that has an RVU of multiplied by a conversion factor of equals an allowed fee of $CPT (new patient) has an RVU of and (established patient) has an RVU of 3.02.The difference in price between the two is what this patient's complaint is about For example: if a husband and wife were seen on the same day and the husband was new to the practice and the wife was an established patient, his balance would be larger than her balance These are not rules that doctor's offices make up that differ from office to officeThese are national,governmental policiesWe are bound by well-established, contractual rules to code claims accurately We legally cannot code a new patient as established patient just to keep their out of pocket costs down This would be a fraudulent insurance claimInsurance companies should have customer service representatives trained and educated to explain these details to their members It seems this was not the case His insurance company left it up to their member and their contracted provider to battle over it; ultimately and unfortunately resting blame with the doctorThank you, Lori GBilling Manager

Thank you for bringing this matter to our attention. Please see our response below: Medical billing is unlike billing for other lines of business.   Medical billing uses a series of codes (CPT codes) and each code is assigned a RVU (relative value unit). These codes describe the services...

performed.  A 99204 is a new patient visit CPT where 99214 is an established patient visit CPT.  There is a formula (conversion factor) that is multiplied by the RVU for the code and that becomes the allowable payment from the insurance carrier.  These conversion factors and RVUs are based on CMS (Centers for [redacted] and [redacted]) policy.  Every insurance company uses some variation of the CMS conversion factor.  They may base their allowed payments on 1.5 times the [redacted] allowable fee.  In very basic terms as an example: a CPT code that has an RVU of 5 multiplied by a conversion factor of 15 equals an allowed fee of $75. CPT 99204 (new patient) has an RVU of 4.64 and 99214 (established patient) has an RVU of 3.02.The difference in price between the two is what this patient's complaint is about.  For example:  if a husband and wife were seen on the same day and the husband was new to the practice and the wife was an established patient, his balance would be larger than her balance.  These are not rules that doctor's offices make up that differ from office to office. These are national,governmental policies. We are bound by well-established, contractual rules to code claims accurately.  We legally cannot code a new patient as established patient just to keep their out of pocket costs down.  This would be a fraudulent insurance claim. Insurance companies should have customer service representatives trained and educated to explain these details to their members.  It seems this was not the case.  His insurance company left it up to their member and their contracted provider to battle over it; ultimately and unfortunately resting blame with the doctor. Thank you, Lori G. Billing Manager