Charging a facility fee is double-dipping. When the Cleveland Clinic began doing this, I immediately called my insurance company to complain.
https://www.cms.gov/medicare/coding/pla ... e_set.html
(I know that the link says Medicare, but the place of service codes apply for everyone, no matter their age. This is across the board, nationwide.)
Please note that all definitions for the various places of services begin with "a facility or location....."
Rates of reimbursement are determined by ‘place of service’. When you go to a doctor’s office for an exam, the place of service code is
11.
Let’s say, that you return to that office a couple of weeks later, and receive an injection for bursitis. The place of service is still
11.
But, if you go to an Urgent Care facility because of acute pain and receive the same injection, the place of service code will be
20. The rate of reimbursement for the same injection will be different, because one was administered in a doctor’s office, while the other was in an Urgent Care facility.
The Urgent Care facility cannot charge an extra fee because of its facility. The procedure is already being paid according to the place that the service was provided.
This logic applies towards all billing practices….. except the CC, because it makes up its own rules.
This fee began appearing on a friend’s bill some years ago. I called his insurance company and explained the situation.
At first, the insurance phone rep didn’t see the problem as I saw it. I persisted. I asked her about the place of service code and asked what was used. She said
11. I said, well.... isn't the rate determined by the place of service? If it's an
11, this proves that the procedure took place in a doctor's office. It took some doing, but bit by bit, she got it.
I suggested to her, that she look at another patient’s insurance claim, within my friend’s network, that was not a Cleveland Clinic claim. Was there a facility fee? Nope. There was not.
She took this very personally, and stressed to me, that my friend was never to pay for this fee. That if the CC threatened him with collection notices, that we were to call her.
I always check his EOB’s (explanation of benefits) to see what the insurance company is allowing vs. disallowing. It is important to do this, as it’s not unusual for the CC to bill for something that has been disallowed.
Never pay a CC invoice, unless the amount due matches the amount due, as according to your insurance company.
Interestingly, whenever I’ve had to call the CC about billing, the rep can never find the EOB.
One must be persistent.
Patients are responsible for paying the deductible, until it is met. Deductibles vary greatly.
Yes, this facility fee is robbery, and if folks don't check their EOB's and contact the insurance company, they will continue to be robbed.
I hope this helps someone. Sorry, if I got a bit wordy.... but, understanding coding can be a bit tricky.