A fee schedule gives rates for a defined set of services or units. To use one in a review, establish which agreement, product and effective period it belongs to, then check its exceptions. The rate file and the terms that explain it should stay together.
Custom amounts and reference-based rates
A custom schedule may specify a dollar amount for a defined service or unit. A reference-based arrangement may apply a percentage to a specified external schedule. In either case, the surrounding agreement can narrow the scope or introduce exceptions.
CMS’s PFS files are one possible public reference. Their availability does not make them the default for every commercial agreement. A negotiated case rate, per diem or other payment method cannot safely be forced into a simple per-service multiplier.
Version the whole rule, not just the spreadsheet
Keep the schedule identifier, received date and effective dates. The date a team downloaded a file can differ from the date the terms apply. A revised workbook should not silently overwrite the file used to calculate an earlier audit.
If an amendment changes only selected services, define which old rows remain in force. Missing information is not the same as zero reimbursement. Preserve the exception and ask for clarification.
Read the hierarchy
An agreement may describe when a special rate overrides a general rate. The hierarchy must come from the applicable terms, not from DueMD or a guess about industry practice. Document an explicit order when the terms support one.
If two documents conflict, the right result may be “review required.” A calculator can apply a chosen order consistently while still applying the wrong legal interpretation.
A general rate and a special rate
Illustrative example.
| Example condition | Calculation | Assumed result |
|---|---|---|
| General rule | $100 reference × 110% | $110 |
| Explicit special-rate override | Fixed rate for Service A | $145 |
| Different product | No applicable schedule established | Do not calculate |
Service A uses $145 only because this example agreement expressly gives the special rate priority. That ordering is not a universal rule for all contracts.
Schedule-selection errors
- Treating the payer name as a unique schedule identifier.
- Using the date a file arrived as the service effective date.
- Replacing missing rows with zero.
- Assuming all exceptions have the same priority.
Before using the schedule
- Record contract, schedule and product identifiers.
- Confirm effective periods and units.
- Map any explicit exceptions and priority rules.
- Test at least one ordinary service and one exception.
Keep reading
Sources
Apply the agreement and records relevant to your review. Examples explain the method; they do not determine a payment obligation.
- PFS documentation and files
- PFS lookup: geographic adjustment and limitations
- PFS status and payment policy indicators
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