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Issue 6 · July 2026
The fee-schedule setting that caps every claim below what your payers would pay — and the filing deadline that turns earned revenue into a write-off
Before you act on any number here: Practice Insider gives general operational guidance on running an independent practice. It is not legal, compliance, tax, or financial advice. Confirm any billing, coding, fee-schedule, payer-contract, or overpayment step with qualified healthcare counsel, a certified professional coder, or your own advisor before acting on it.
The lead: the fee-schedule setting that caps every claim below what your payers would pay
Every practice sets a fee schedule — the list of charges it bills for each code — and most set it once and never revisit it. Underneath every claim sits a rule that makes that neglect expensive: a payer reimburses the lesser of your billed charge or the contracted allowable for the code. Bill above the allowable and the contract rate governs, as it should. But bill at or below the allowable on any code, and you have quietly capped your own payment at the lower number — the payer keeps the difference and never tells you.
Set your charges at a consistent multiple of the current Medicare allowable — commonly 200% to 300% — so the contracted rate is always the binding number, never your own fee. A charge master left at old dollar amounts almost always has codes that have drifted below what a payer would have paid, and every claim on those codes underpays by the gap.
You can find the leak in one remittance. Pull a recent explanation of benefits or electronic remittance and read two columns side by side: the amount you billed and the amount allowed. On a correctly set fee schedule the allowed amount is always the lower of the two. Any line where your billed charge equals the allowed amount is a code where you may be capping yourself — the payer paid its full contracted rate only because you happened to bill at least that much, and on its next fee increase you will fall behind it without noticing.
What to check this week
Pull your top 15 to 20 codes by revenue and compare each billed charge to the current Medicare allowable for your locality. Any code billed under roughly twice Medicare is worth a second look, and any code billed at or below your best commercial contract's allowable is leaking on every claim. Raising your charges never makes a contracted payer pay above the contracted allowable — but it stops you from billing below it, and your charge is also the number a self-pay or out-of-network patient is billed against. Reset charges to a clean multiple of Medicare across the board rather than guessing code by code.
Quick hits
Billing: the filing deadline that turns earned revenue into a write-off
Every payer sets a timely-filing limit — the window from date of service to get a clean claim in the door. Medicare allows 12 months; commercial payers commonly run 90 to 180 days, and some Medicaid and plan-specific windows are tighter. Miss it and the claim is denied for timely filing, an almost impossible denial to overturn, and in most contracts you cannot bill the patient for a claim you filed late. It is one of the few denials that is a total, permanent loss of money you already earned. The usual culprit is not slow billing — it is a claim that fell into a hold or rejection queue and sat there unwatched until the window closed. Know each payer's limit, and clear your claim-hold and clearinghouse-reject queues on a fixed weekly cadence so nothing ages into a deadline nobody was watching.
Compliance: the credit balance that becomes a legal problem at day 60
Credit balances — money a payer or patient overpaid — pile up quietly in every billing system, and most practices treat them as a bookkeeping chore to get to later. For government payers they are a deadline. Under the federal 60-day rule, once you identify an overpayment from Medicare or Medicaid you have 60 days to report and return it; hold it past that and a simple overpayment can become a False Claims Act exposure with penalties far larger than the balance itself. Patient credit balances carry their own state-law refund deadlines and unclaimed-property rules. Reconcile your credit-balance report monthly, refund identified government overpayments inside the 60-day clock, and do not let a five-figure pile of other people's money sit on your books as if it were revenue — it is a liability, and an audit reads it as one.
Coding: the modifier that gets you paid for a same-day visit and procedure
When you perform a significant, separately identifiable evaluation-and-management service on the same day as a minor procedure or a preventive visit — a new problem addressed alongside a scheduled injection, wound care, or an annual wellness visit — the E/M is separately payable, but only if you append modifier 25 to it. Leave it off and the payer bundles the E/M into the procedure and pays nothing for the visit, forfeiting a payment commonly worth 75 to 175 dollars for an established-patient E/M. The rule cuts both ways: modifier 25 is a known audit target, so the visit has to be genuinely separate from the procedure and the documentation has to stand on its own. Check whether your most common same-day procedure-and-E/M pairings carry modifier 25 when the work supports it — a single missed pairing a day is real money over a year, and a misused one invites a review.
Putting this issue to work
If the fee-schedule and filing-deadline numbers landed, the question is whether your billing operation is set up to catch them — or whether an outside billing and RCM service would do it better. Compare medical billing and RCM services on GetPracticeHelp and filter by your specialty and payer mix before your next renewal or hire.
Compare billing and RCM services →On the numbers: lesser-of reimbursement mechanics, charge-to-Medicare multiples, timely-filing windows, the federal 60-day overpayment rule, and modifier-25 payment and audit norms reflect general medical-practice-management and federal-program guidance (MGMA-style benchmarking, CMS rules, and payer-published policies). Your specialty, payer mix, contracts, and state will move the specifics — treat these as anchors to check against your own data and contracts, not guarantees.