Healthcare Business DEMYSTIFIED

de mys ti fy - to make less mysterious, clarify

What is a fee schedule?

The fee schedule is often mentioned when talking about payments made to physician's offices.  A fee schedule is used by all payers to assign payment to a physician.  The fee schedule is a master list of all CPT codes and the dollar amount that the insurance company is willing to pay for that service.  Please read the topic "How does my doctor get paid?" to learn more about the link between CPT codes and fee schedules.  Each insurance company maintains their own proprietary fee schedule and within the insurance company there are many different fee schedules.  Insurance companies do not readily share their fee schedules with doctors, patients or other insurance companies.  They consider this to be a trade secret and guard the information closely.  You can begin to see what they have negotiated with your physician by studying your EOB when it comes in the mail.  Look at the contracted amount column to learn what dollar amount your physician has agreed to accept for that particular service.  (see the Topic "How to read an EOB" with help in locating this information)  They can vary by region, town, county, specialty, size of practice, etc.  The practice may have negotiated a special fee that applies only to them.  The fee schedule that is assigned to the physician is loaded into that physician's account so that any time a claim comes in from that office, the appropriate fee schedule is applied to that claim.  If the physician has any special changes to the fee schedule, those changes are also loaded.  The fee schedule stays in place until it is renegotiated.  It is not an automatic occurrence to have the fee schedule updated and small practices can go several years without any change to their fee schedule.  Larger practices and practices associated with hospitals and large organizations get their fee schedules updated on a more regular basis, most likely, yearly.