Question

This week's homework is based on the reading for chapter 12 and deals with Medicare fees and limiting charges. This case study is due by end of day Friday. Fill out the information below and determine the amount owed by the patient after the deductible has been met in the following situations. Provide the calculations used to determine your answers:

A. Participating physician’s standard fee: $300.00 Allowed amount $200.00 Medicare pays 80% Patient or supplemental plan pays 20%: Provider adjustment (write-off):

B. Nonpar physician’s standard fee (accepts assignment): $250.00 MFS: $200 Medicare nonpar fee: Medicare pays 80%: Patient or supplemental plan pays 20%: Provider adjustment (write-off):

C. Nonpar physician’s standard fee (does not accept assignment): $250.00 MFS: $200 Medicare nonpar fee: Limiting charge: Patient billed: Medicare pays patient: Total provider can collect: Patient out-of-pocket expense: Provider adjustment (write-off):

Answer 1

A)   Participating physician’s standard fee : $300.00

       Allowed amount: $200.00

       Medicare pays 80%: $160 ($200 * 80%)                     

       Patient or supplemental plan pays 20%: $40 ($200 * 20%)                                              

       Provider adjustment (write-off): $100      

B) Non par physician’s standard fee (accepts assignment) : $250.00

MFS: $200

    Medicare non par fee (95% of MFS) = $190   

    Medicare pays 80%: =$152 ($190 * 80%)  

    Patient or supplemental plan pays 20%: = $ 48 ($190 * 20%)   

    Provider adjustment (write-off): $50

C) Non par physician’s standard fee (does not accept assignment) : $250.00

     MFS: $200

     Medicare non par fee (109.25% of MFS) = $218.50   

   Limiting charge : =115%

    Patient billed : $218.50

     Medicare pays patient : 0   

     Total provider can collect : $218.50

Patient out-of-pocket expense : $218.50

Provider adjustment (write-off) : $31.50