User Guide — Allowable and Fee Schedules

To access allowable and fee schedules, you must have one of these permissions:

• Practice Set-Up: Fee Schedules/ Procedure Codes/ Groups/ Modifiers
• View Fee Schedules

An allowable schedule is a table of procedure codes and the corresponding amounts that you expect to receive in payment from a particular payer. You can create allowable schedules manually or provide athenahealth with a spreadsheet of procedure codes and amounts so that athenahealth can import the schedule for you.  

For a procedure code to be valid at the time of charge entry, it must have an entry in this schedule. If it does not, an "unknown procedure code" error message appears.

What are local allowable categories?

Local allowable categories allow you to define groups of payers, their products, and plans and assign them to an allowable schedule. You can use the Local Allowable Categories page for setup and maintenance of your local allowable categories.

Create and maintain local allowable categories

The Local Allowable Categories page allows you to create and maintain the payers, products, and plans covered by an allowable schedule. Local allowable categories are created by combining any of the following insurance package attributes: Insurance Reporting Category, Product Type, and Insurance Package. Local allowable categories are then linked to a practice-defined allowable schedule.

A fee schedule is a table of procedure codes and the corresponding fees charged by your practice under a contract with a particular insurance package or allowable category. (An allowable category is a group of insurance packages that use the same allowable schedule.) You can create fee schedules manually or provide athenahealth with a spreadsheet of procedure codes and fees so that athenahealth can import the schedule for you.

Your practice can have only one fee schedule and one allowable schedule in effect for each insurance package or allowable category. Fee schedules and allowable schedules with the same allowable category and departments must not have overlapping effective or expiration dates.

A default fee schedule is a table of procedure codes used in your practice with the corresponding fees charged by your practice, independent of any payer or insurance package. Every practice has one default fee schedule. It should contain an entry for every procedure code that will ever be used in your practice.

The default fee schedule amounts are used whenever a payer-specific fee schedule lacks a particular procedure code, or when no payer-specific schedule exists. Procedure codes and their fees must be found in this default schedule in order for the procedure code to be valid at the time of charge entry.

With the exception of athenaEnterprise organizations, only one default fee schedule can be in effect for your practice at any given time. (If yours is an athenaEnterprise organization, refer to Department Fee Schedules.)

You populate the default fee schedule manually, using the Fee Schedules page.

athenahealth maintains a comprehensive list of all known insurance categories (payers) in the United States. Every insurance package is assigned to an allowable category by athenahealth. An allowable category is a group of insurance packages that use the same allowable schedule. When an insurance package is assigned to a patient claim and charges are entered, athenaOne checks for an allowable schedule for that insurance package's allowable category.

If automatic adjustment has been enabled for that allowable schedule, the contractual adjustment occurs immediately upon charge entry. (Refer to the Auto write-down contractual amount at charge entry? and the Auto write-up contractual amount at charge entry? fields on the Allowable Schedules page.) Automatic adjustment of contractual amounts results in more accurate Accounts Receivable data. (Note that claims will still be billed at the full fee schedule amount.)

It is important to record the expected coinsurance percentage (if there is one). When this percentage is recorded on the Insurance Policy Details page, the expected coinsurance amount appears on the Claim Review page when a claim is created. The coinsurance amount is marked "unpaid, expected co-insurance, not yet a formal charge."

If your practice has the payer's allowable schedule in athenaOne, and the procedure code is included in the allowable schedule, the expected coinsurance amount is 20% of the allowable.

If the payer's allowable schedule is not in athenaOne (or if the allowable schedule lacks the procedure code) the expected coinsurance amount is 20% of the charge amount from the fee schedule.

A payment mismatch occurs when an insurance company either underpays or overpays your practice (according to the payer's allowable schedule) for a service or procedure. The Payment Mismatch Tracking report helps you identify such payments.

You can use the Payment Mismatch Tracking report to identify (and dispute) contracted payment amounts with payers. To use this report, your practice must have payer-specific allowable schedules configured, including minimum and maximum acceptable values. Only charges that are associated with an allowable schedule appear in the Payment Mismatch Tracking report.

Note: If the Payment Mismatch Tracking report results show charges in the "unknown" columns, those codes are not currently listed in the allowable schedule. If all charges appear as unknown, it is possible that no allowable schedule is configured for this payer, or that the allowable schedule is configured incorrectly.

athenahealth recommends defining this allowable information for the top 15 procedure codes for the top 4 payers. To properly configure this information, you should contact the athenahealth CSC by selecting Support > Create Case or Call in the Main Menu.

You need allowable schedules with the appropriate insurances and procedure codes to compare capitation payments effectively to their fee-for-service equivalents.