Quick Tips: Deductibles, What to Charge When

Deductibles make what to charge clients confusing for both in-network and out-of-network providers.

Let’s look at some examples of benefits.

In-Network:

• Contracted rate is $100 for 90791 and $50 for 90837
• Deductible: $500 with nothing met
• Co-insurance of 20%

This means the client would pay you $100 for the first session (contracted rate of 90791) and $50 (contracted rate of 90837) until they meet their deductible (8 sessions). This is 100% of the co-insurance due to the deductible.

Once they meet their deductible they would have a co-insurance of 20% or 20% of the CPT code you bill. For 90837 your contracted rate is $50, the client would owe you $10 and the insurance company would pay you $40 to meet your contracted rate of $50.

Can only charge the client your contracted rate if you are in-network. 

• Request a fee schedule from the insurance company
• Look on the EOB you receive for the ‘allowed amount’

Here’s a more complicated example:

• Contracted rate is $100 for 90791 and $50 for 90837
• Deductible of $500 with $450 met
• Co-insurance of 20%

The client would pay $50 for the first session (90791–contracted rate of $100) to meet the deductible and then 20% of what is left of the contracted rate ($50) or $10 for a total of $60. The insurance company would pay $40 to equal the contracted rate. Since they met their deductible, they would pay $10 until their deductible resets (20% of 90837 rate of $50) and the insurance company would pay $40.

Out-of-Network:

• You can charge the client your full fee due to not having a contracted rate.
  • Say your full fee is $150 and they have an OON deductible of $1,000.
    • What gets applied to the deductible is what is called the UCR (Usual Customary and Reasonable Rate)
      • Say it’s $90.
    • Only $90 of what the client paid you ($150) would be applied to the deductible.
  • Since you are OON, you can charge the client your full fee do not have to go by the UCR rate (“balance bill”).