How to find out insurance reimbursement rates by CPT code

Posted
by JeanettePNP JeanettePNP, MSN, RN, NP Member Nurse

Specializes in Pediatric Pulmonology and Allergy. Has 8 years experience.

I know how to look up Medicare reimbursement rates on their website. But how do you get this information for individual insurance companies.

I get paid a salary and don't have anything to do with billing directly, but I would still like to have a better idea what my services are actually worth.

TX RN

TX RN

Specializes in ICU, CV-Thoracic Sx, Internal Medicine. Has 11 years experience. 255 Posts

Ask your employer for a copy of EOB's.

This should list each patient and what rate is reimbursed by payor source.

You can review each charge.

JeanettePNP

JeanettePNP, MSN, RN, NP

Specializes in Pediatric Pulmonology and Allergy. Has 8 years experience. 1 Article; 1,863 Posts

Another question.

Once I am credentialed through my work with an insurance company, is that only for as long as I hold this job? If I change jobs, will I have to start the credentialing process all over again? (Assuming that they accept the same insurances.)

itsmejuli

itsmejuli

Specializes in Home Care. 1 Article; 2,188 Posts

I used to work for a medical insurance company.

Reimbursement is not at all simple. There are many contracts and rarely are they straight forward.

These contracts are also confidential information.

RainMom

Specializes in PACU, pre/postoperative, ortho. Has 11 years experience. 1,113 Posts

Any ins company you are credentialed with should have supplied you with a CPT list with allowed fees. Also if you are friendly with your billing dept, a good CPT book (updated yearly) will give RVU (relative value units) for each code. Multiplying the RVU by your region's assigned "value" will give a suggested ballpark fee for each code. Comparing your calculated fee to what an ins will actually pay will help you decide if being in-network is worth it.

TX RN

TX RN

Specializes in ICU, CV-Thoracic Sx, Internal Medicine. Has 11 years experience. 255 Posts

Another question.

Once I am credentialed through my work with an insurance company, is that only for as long as I hold this job? If I change jobs, will I have to start the credentialing process all over again? (Assuming that they accept the same insurances.)

Yes.

You are credentialed through the groups number. You essentially receive a billing number that is tied to the groups practice.

If you leave the practice you will need to restart the credentialing process for your individual number.

cayenne06, MSN, CNM

Specializes in Reproductive & Public Health. Has 10 years experience. 1,394 Posts

And THIS is a big reason why health care costs are out of control in this country. Not only are consumers prevented from finding out exactly how much a hospital or provider charges for a service, the provider HERSELF often has no idea how much the service costs! This is crazy!

(hope it's clear this isn't a dig on you, OP. Billing should be straightforward for both patients and clinicians- it's crazy that you would have to consult multiple resources and do algebra to come up with a "ballpark" price for your services!)