When you run a busy pediatric practice focused on providing top-notch clinical care, it can be difficult to find time to think about finances. After hours care is a service that many practices provide, whether or not they get paid for it. In order to run your practice like the business that it is, it's important to identify where you are leaving money on the table, and make changes to strengthen your revenue cycle.
You’re Leaving Money on the Table When You Don't Charge for After Hours Care
Some insurance carriers deny paying after hours codes, and instead make the charges 100% patient responsibility. That means the patient still has to pay whatever copay or deductible amount they owe as well as the additional after hours charge. Knowing this, many pediatricians end up not billing these codes in order to save their patients the extra cost. But this is something that they can and should do.
The following statement is something to keep in mind when talking to patients about the additional fee you will be charging for their after hours appointments:
“There is an additional expense to deliver the high quality of care that we promise you, and that comes with costs.”- PCC’s Jan Blanchard, CPC, CPEDC
If you have never charged for this service before and you plan to start, the success of your endeavor will lie in setting appropriate expectations with your patients ahead of time. Don’t just spring a fee on them that they aren’t expecting. Let them know weeks or months prior to starting. If they wonder why they should have to pay for something they never had to pay for before, you can explain that you had the option to charge all along but chose not to. Let them know there are costs involved in providing this extra service – from hiring staff to cover the extra hours, to the overhead associated with keeping the office open – and that this fee is needed to help offset those costs.
Most people are used to paying more for premium timeframes in other settings… think high season versus low season hotel rates. People pay more for the same room just to stay in it at their desired time. After hours care can be thought of in the same light. You are offering a primetime service, and should be compensated accordingly.
Pediatricians are notoriously kind, and providing after hours care without charging is an example of that kindness. But remember, until you value your own time, you cannot expect your patients to. So, set the expectation and take care of yourself as much as you take care of your patients.
Some Payers Do Not Cover After Hours Charges, and Do Not Allow You to Charge Patients Either. Why Bill Codes That You Know Will Not Be Covered?
It’s important to bill after hours codes even if payers don’t cover them because if you do, a year from now you’ll have a bank of data you can extrapolate from in your next insurance negotiations. You can say with certainty rather than guessing, “this is how many patients I saw after hours.” You’ll be able to prove that you actually saved the payers money by seeing children after hours, and keeping them from an ER visit which would have cost the insurance company a lot more money. This information will help you negotiate getting payers to cover these codes at fair rates.
What You Need to Know About Coding and Getting Paid for After Hours Care
When you provide after hours care, you still bill your regular visit codes (e.g., well visit, sick visit), and the after hours code is an additional code on top of that.
Know What Codes to Use
99050: Services provided in the office at times other than regularly scheduled office hours or days when office is normally closed. Holidays, Saturdays, Sundays, or after closing time on a day you are already open all fall into this category. For example, if you close at noon on Saturday but come back in or stay late to see a patient at 4pm on that Saturday, then 99050 should be added on when you bill the visit.
99051: Pertains to services provided in the office during regularly scheduled evening, weekend, or holiday hours. This is the code to use when you are seeing patients during your established after hours times.
99056: This code is less common, but still perfectly fine to use. It refers to services typically provided in the office, but currently provided out of the office at the request of patient (e.g., a house call after hours). An added bonus, you technically could use one of the above after hours codes if it falls into the correct time frame plus this code if you do a house call.
Set Your Fees
Medicare tends to set the standard industry-wide, and providers often set their fees in relation to Medicare’s RVUs. RVU stands for Relative Value Unit, and it’s a dollar amount that is the outcome of a complex calculation to determine how much each code is worth.
Medicare currently does not have any RVUs associated with 99050 or 99051. So, what to do? Take a look at the fee schedules of each payer you are contracted with and set your fees for these codes above their allowed amounts. There is enough advocacy for increased payments going on, that if someone in your region argues and wins an insurance payment increase for your geographic area, you won’t get a payment increase unless your rates are already above the minimum. If a payer sees you are charging exactly what they pay, they will think you don’t expect more. If your fees are already above the minimum, you still may not get all of what you are charging but you will receive whatever blanket increase is being offered.
Boost Your Revenue Over Time
While payments from these codes may not be huge, they do add up over time, so it is worthwhile to bill them. You can roll the money you get from them back into the business to cover the cost of staffing and overhead for after hours appointments so that you break even or make a profit versus running at a loss.
By charging for after hours appointments, you will be taking a step closer to operating your practice as a business, while simultaneously providing high quality clinical care.