Why You Need To Fix Your Pricing RIGHT NOW!

As you should be aware, the 2021 RBRVS values have a significant impact on the relative value of some key procedures important to pediatricians, especially E&Ms.

Normally, annual RVU changes adjust the values of each code by incremental amounts.  This year, however, E&Ms have increased by more than 20%, which puts many pediatric practices in danger of leaving real money on the table.

Let's review the salient facts:

  • I typically recommend that practices write off at least 20% of every EOB line-item charge.  Why?  Because many insurance contracts (which I AM SURE YOU HAVE HANDY) have little sneaky language in there that reads something like this: "We will pay you our fee schedule or XX% of your charges, whichever is lower."  That XX is often a number like 80% or 70%.
  • Although most payors haven't flipped to the 2021 RVU values yet, Tricare, many Medicaid programs, and some private payors already have.
  • If your pricing is such that- for example - your BCBS E&M charges are 20% higher than your fee schedule now, when BCBS turns on the 2021 values,  you may not see the increased fees!

Let's walk through an example using easy math.

2020 99213 Charge - $100
2020 BCBC Payment - $75 (75% of your charges)
2021 BCBC Payment - $90 (90% of your charges)

If BCBS will pay you their fee schedule or XX% of your charges, whichever is lower, you will lose money any time XX is more than 90%! [And I've never seen a 90% figure - it's always 60-80%.]  Do you see how when BCBS catches up to 2021, you may not know it?

Worse, a number of key pediatric procedures have dropped this year, so those payments will drop right away regardless of your charges.

We saw the same thing happen with the imms admin codes a few years ago and watched as pediatric practices were slow to update their fee schedules.  It's mid-February now, go to it.

If you're not a PCC client, you'll want to use the 2021 RVU Calculator.  If you're a PCC client, you have this data in your system and can do the work yourself or call us to give you a hand.