How is Anesthesia billed?


Anesthesia is billed by units using base + time.  Procedures are usually coded by a Certified Professional Coder and assigned a CPT code. CPT codes are assigned a base unit value by CMS (Centers for Medicare and Medicaid Services).  Those base units are added to the time units (usually 15-minute increments) and then that is multiplied by a conversion factor to get your billed amount.  There are sometime additional charges such as having pain blocks or for very young or very old, etc.
  • Example: Let’s say you have to have your appendix removed and it takes 30 minutes and you are an otherwise healthy adult.  An appendectomy CPT code has a base unit value of 6 and 30 minutes is 2 time units. If you have a billed conversion factor of $100, your bill would be $800.

How is Anesthesia paid by insurance?
  • Anesthesia is one of those things you usually don’t get a choice in.  They are usually hospital based and the same group covers that hospital.  They usually don’t have a choice in you. Most treat every patient the same. They usually don’t know if you have the best insurance or have no insurance. Also, unlike your surgeon or primary doctor, they don’t get to inform you that they are not in your insurance network or that you have a deductible or give you an estimate of your bill.  Usually they meet you during your pre-op assessment and are more worried with making sure that you stay alive and receive the best quality care than how much money they will make.
  • Anesthesia is paid differently by different commercial insurance carriers base on the contracts that the doctors have with the insurance companies.  Some contracts are based on billed charges and others pay based on conversion factor.Example if your insurance carrier has a contract to pay 90% of billed charges with your $800 bill above, there would be a provider discount of $80 leaving $720. Now let’s say you have an 80/20 plan through your insurance, and you have met your deductible, your insurance would pay $576 and your provider would bill you $144.Example if your insurance carrier has a contract for a $85 conversion factor: Your $800 bill would have an approved amount of $680 (8 Units x $85) and if you have an 80/20 plan, your insurance would pay $544 and your bill would be $136.
  • If you have Medicare or Medicaid, your claim is paid based on a published conversion factor for each based on different states.  Medicaid for North Carolina has a conversion factor of $17.40 and Medicare is $21.62. With your Appendectomy above, your provider will be paid $139.20 by NC Medicaid and $172.96 by Medicare.
  • If your anesthesiologist isn’t in network with your insurance, your insurance may not pay any, pay a small portion or apply a separate Out of Network Deductible.  When this happens, you may be responsible for the full amount of the bill.

Am I being charged a fair rate?
  • Usually the only portion of the bill that the doctors set a rate for is the billing conversion factor.  Almost every group has a different rate and it usually reflects the cost of living for that region.
  • There are several websites that can be used as tools to give you estimates for your area. I usually refer to FairHealthConsumer.org or Healthcare Bluebook.  These sites list the average charge for your area and what an average reimbursement rate for insurance.  They are not 100 percent accurate since the length of a procedure can affect the rate, but they give you an idea.

FAQ:
  • Can I have a discount? – It depends.  Usually discounts can only be given to patients without insurance.  Providers usually cannot give discounts on Deductibles and Co-Insurance (the 20 part of the 80/20).
  • What if I don’t have insurance? – As soon as you receive your bill, call and ask for a discount.  Most people at the billing agency are compassionate and understand people in different financial situations.  They can tell you about discounts, financial assistance programs and setup payment plans.  They sometimes can give you a substantial discount for paying promptly. If you wait until your bill goes to a collection agency, they may not be able to give you any discounts.
  • Why are you in network with my insurance? – There are a number of reasons that a provider might not be in network with your insurance.  Some insurance companies don’t pay timely, some won’t negotiate with a doctor and yes sometimes it is a money issue.
  • I don’t have Medicare. Why did my insurance pay a rate based on Medicare? – Some insurance carriers use Medicare rates or a percentage of Medicare rates for out of network providers.  Why? My guess is that Medicare rates are a publish rate and they are low rates. Medicare in NC essentially pays anesthesiologist $86.48/hour which is around what car shop charge for mechanics.
  • I think my bill is wrong. - Call your provider and don’t wait.  It is your responsibility to make sure your bill is paid by your insurance and that it is paid in full.  If you wait too long you might be turned over to a collection agency and take a hit on your credit score.
  • I don’t agree with what my insurance paid or allowed. – Call your insurance company at the number on the back of your card or refer to insurance benefit guide. You might have to file a written appeal. If you do, make sure you state every reason that you think that they should have paid differently. If they paid out of network, some insurance policies have provisions to cover anesthesia as in network if performed at an in-network hospital and an in-network surgeon. Check and see if there are any in-network providers in a 25 or 50 mile radius. Use a website such as above to find out what reimbursement rate for the area and use that.
  • If you can’t get any result from your provider and insurance and you feel that they are in the wrong, contact your state’s department of insurance and see if they have a patient advocate that can act on your behalf or review your case and give you advise.

Final notes: Anesthesiologist are specialized physicians.  They have gone to college, medical school, done residencies anesthesia school and residencies again.  Usually that is around 14 years of not being paid and racking up loans for school.  This doesn’t include continuing education and learning new techniques and procedures.  They have high stressed jobs and cover hospitals 24/7/365.  They do specialized procedures that can result in permanent damage or death if they are off a couple of millimeters.  Before I got in the business, I thought that all doctors were extremely rich and driving around in their high-end luxury cars and living in their huge mansions. The truth is that many drive older cars and live in the same neighborhoods as you and I do. Many are involved in their community and go to church.  Yes, there are some exceptions to this.
 
** This is my personal opinion and assessment. Examples given are examples and not a reflection of any client or patient.  The views expressed are not of my employers, physicians or patients.**


Comments

Post a Comment

Popular posts from this blog

Billing 101 for patients

Have you ever gotten a bill from the hospital or doctor and it doesn’t match your EOB from your insurance company?  Don’t always blame your doctor. There are a number of different reasons this can happen.  Bills are often sent to you automatically by a company’s billing software. Sometimes it is a true error. Sometimes it is because your provider is not in network with your insurance carrier.  Let’s do a little background on how the bills come to be from the billing side. Most billing companies use some sort of billing software.  Once they enter your information and insurance information (demographics) they will enter the charges and bill your insurance (file a claim). Some insurance companies pay very quickly, especially if the claim goes to them electronically.  Other insurance companies are slow at paying or don’t pay at all.  Most billing software has parameters are setup where if a claim isn’t paid within a certain amount of time they will rebelle...
Read more