Contract Compliance Error: Case Rates
Background – Facility contract pays $1,200 outpatient case rates for (1) Chemotherapy and (2) Infusion Therapy, with drugs paid in addition to above case rate at 45% of billed charges. Facility’s “default” outpatient rate pays 65% of billed charges (whole bill).
- Chemo case rate triggered by billing of a chemo revenue code (330-9) and a chemo CPT code (96401-50)
- Infusion case rate triggered by billing of an infusion revenue code (260-9) and an infusion CPT code (96365-79)
Errors Identified – When chemo revenue code is billed with infusion CPT code, or vise versa, rules do not fire and default outpatient rate is applied.
Root Cause – Adjudication system limitations miss the ‘Revenue Code/CPT’ mismatch when billed.
Savings Recovered – $1,000,000+ for single facility