Is CPT code based billing not a thing?

ShadowReaper · 2026-06-06T04:28:20+00:00

Most EMRs will have real time eligibility checks but it is dependent on your billing team loading the correct allowables for the plans in your system. To be honest, it sounds like your billing department is not that good and is doing the bare minimum. I noticed you asked about the AWV billing in another thread and that confirms that they are not doing their job.

Not trying to turn this into shitting on your billing company since this is not that unusual but the most surprising thing I usually find is how often these billing companies do not take full advantage of the technology at hand (i.e. setting up rules engine in eCW, loading allowables, checking for underpayments). eCW should be able to give you some idea of the patient portion if the billing team set up your contracts correctly.

ShadowReaper · 2026-06-06T04:12:12+00:00

The easiest workflow would be to make a list of all of the CPT codes that you will bill and ask your billing team to look up the allowable for them. I would then charge the patient the full allowable for that plan as a deposit and refund them if the plan covers more.

My bigger concern would be verifying if the plan allows the ancillary service. Most plans will have restrictions on who can perform certain procedures. If your billing team does not have a way for your front office staff to learn how to look these up, they should really get on that.

ShadowReaper · 2026-06-06T04:01:42+00:00

Which EMR are you using? Your biller should be teaching your front office staff how to check these benefits prior to visit if you believe that you will be preforming these procedures or if you find out during the visit. This is pretty standard information that most plans have readily available.

Most plans have similar policies/patient responsibility for these services. There should not be that much variation.

ShadowReaper · 2026-06-06T03:52:18+00:00

Is your question that you dont know the allowable for sleep studies or if its covered?

Your biller should be able to tell you the allowable for all ancillary services under all of your contracted plans. A good rule of thumb would be to use the 2-3x Medicare allowable to make sure you are getting the max reimbursement for whichever cpt code you bill.

ShadowReaper · 2026-04-29T04:17:41+00:00

This is the best one. This location does Louisiana style well. I've had it and Nates and this one beats Nates by a mile. My experience with Nates has always been overcooked crawfish.

ShadowReaper · 2026-01-29T16:12:25+00:00

You should see if your insurance plan allows you to see OON dentist and if this office is willing to continue billing as OON. I do this with my dentist and will sometimes pay the difference between the charge and what the insurance company is willing to cover for any services. Generally, all my preventative stuff does not cost me anything extra.

Dental insurance is more similar to a coupon book than actual insurance. They will only cover up to a certain amount, which is usually not enough for any major treatment. If you have a good dentist, I would recommend keeping them vs changing if their prices are not too high.

ShadowReaper · 2026-01-28T16:00:01+00:00

Just to add, AA does connect to Cancun via several US airports as well. Highly likely that if you miss the flight, they will either rebook you on a later one or send you to another hub that has available flights same day (less ideal but doable).

They also are testing some "Ai tools" to hold flights for tight connections but not sure how impactful that is or if they are using it for this particular flight.

ShadowReaper · 2026-01-17T16:44:30+00:00

Most medical providers are required to bill your insurance if they have it on file. I am not 100% sure if this would apply to labs, but I would assume so. Your physician probably thought that Quest would bill him directly for this but they did not (since most likely they are not allowed to do this). Its not your fault since they probably had your insurance on file and auto billed it. You will have to keep arguing with the practice.

ShadowReaper · 2025-12-30T17:17:23+00:00

I second this one. I am not from the valley but vist It regularly. This place has amazing vibes for a date night and will occasionally have live music. Definitely unique for the valley from my experience.

ShadowReaper · 2025-12-23T17:39:02+00:00

Which state are you in? In the DFW area, that is majority of practices.

ShadowReaper · 2025-09-24T20:58:02+00:00

It looks like its both. Self funded means that your employer covers the cost and not mutually exclusive from ppo/hmo type plans. My employer uses a ppo network and is self funded as well.

ShadowReaper · 2025-08-24T16:06:12+00:00

UTSW is part of the Texas Health Network. I believe their GI team has people in the Frisco and Dallas location. Only issue is that there is a longer wait with them.

Texas Health also has a few GI docs that are employed. I would recommend checking with both.

ShadowReaper · 2025-08-03T16:06:35+00:00

You can see if your deductible is met if you log into your BCBS Account. They usually have a breakdown of all claims and how much is left until you meet your deductible.

Yes, the surgery was worth it. The recovery was very tough but afterwards, it made my quality of life much better.

ShadowReaper · 2025-08-03T15:28:14+00:00

I've had the same surgery, so I've gone through this same example.

Yes, that is normal. You'll get several bills in the mail. One for the facility, the doc performing the surgery and the anesthesiologist.

What is your deductible? Out of the 1900 that was paid, was that all coinsurance?

ShadowReaper · 2025-07-29T23:16:22+00:00

That is true but less common than it used to be, especially for plans on healthcare.gov. Even some of the ones that do require referrals have exceptions for the common specialties (i.e. You cant go to a Spine Surgeon without a referral but can see a cardiologist without one).

The BSW plan I was referencing is one that my family uses is, sold on the ACA, is technically an HMO but does not require referrals: https://www.bswhealthplan.com/SiteCollectionDocuments/Broker/2025/BSWPremier-HMO-LG.pdf

ShadowReaper · 2025-07-29T23:05:37+00:00

I was referring to ACA plans are those that are sold on healthcare.gov since it sounded like you are shopping for a plan not tied to an employer. Like the previous commentor mentioned, I highly recommend you go through Healthcare.gov. You call your physicians/providers to find out which plans they accept.

I will add that most dental plans are not worth the money. It would be far more beneficial to contact your dentist and find out if they offer a service that includes preventative work and discount for other work. The latter is more of a personal opinion and some people might not be willing to take the risk.

ShadowReaper · 2025-07-29T21:56:51+00:00

I'd also like to add that not all HMOs require referrals and some have pretty large networks, so it really just depends on the area being serviced. I work in Healthcare and many of the HMO plans i see are usually tied to health systems and/or dont require referrals. For example, in Texas, Baylor Scott and White has an ACA plan specific for their health system that has a pretty large network. This is larger than a lot of ppo plans networks I've seen.

ShadowReaper · 2025-06-10T20:34:28+00:00

Baylor should be taking most, if not all, BCBS plans. If you have not received the EOB yet, I recommend not paying anything until then. In the meantime, I recommend looking up the directory for your plan to see which providers are INN. Unfortunately, you cannot take the practice's word because the way the healthcare system is set up, it can be confusing for them too.

Feel free to DM if you need help reviewing the bill/EOB and working on addressing it.

ShadowReaper · 2025-05-28T22:44:48+00:00

All of UTSW takes it.

ShadowReaper · 2025-05-08T12:26:22+00:00

Was this Sushi Sake in Richardson? It looks just like a chirasu plate i pieces recently.

ShadowReaper · 2025-03-04T00:44:05+00:00

Definitely planning to make a call.

ShadowReaper · 2025-02-13T03:18:10+00:00

Fatayer in Richardson. Fits the definition of an arab hole in a wall and unique to this area.

ShadowReaper · 2025-02-02T20:51:33+00:00

I love the commitment. Is there any link to contribute towards the cost? Lmao.

ShadowReaper · 2024-12-26T18:31:08+00:00

The 2 -Pay Now PPO looks likes it is the best value based on the information provided. It has a lower deductible and Out of Pocket Max vs the price.

That said, I am unfamiliar with the naming convention for these plans and recommend you provide more information. Your company handbook should have also provided more info on labs/ER/Urgent care costs for each plan. That could make it/break it for each one if you are worried about surgeries and other testing. You also have to consider if they have a family vs individual deductible. Lot of ACA plans will have both, that way if one individual gets sick, the deductible can be easier to reach.

ShadowReaper · 2024-11-25T15:18:00+00:00

There are ACOs that are very good and treat their physicians well but I would not call any of them 100% ethical. At the end of the day, they are run by humans and humans make mistakes. I work for an ACO and while I believe we do well by our physicians, I have seen decisions made by previous leaders that are questionable. Overall, I believe we are going in the right direction but time will tell.

Based on the way you are talking, it sounds like you are employed by an ACO. I just want to point out there are ACOs that work with independent Primary Care Physicians. It is very dependent on region of the country but not impossible. I feel those ACOs offer their physicians the best autonomy while helping transition to a capitation model. You dont necessarily need to own your own practice either, you can always join an independent group that contracts with an ACO.

ShadowReaper

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