You work for a billing service and have been assigned the duty of calculating what the patient owes and what the insurance company owes, so you can determine what revenue to expect for these
You work for a billing service and have been assigned the duty of calculating what the patient owes and what the insurance company owes, so you can determine what revenue to expect for these services. You have been given the description of the Service, the Charge and the Usual, Customary, and Reasonable (UCR) amount. The reimbursement will be calculated on the 80/20 distribution once the deductible has been met. All patient deductibles have been met so you do not need to take that into consideration. Under this insurance plan, there is a $20.00 Copay due for Physician Visits (but not for other services) prior to the calculation of payment. Use the data in the table below to fill in the Copay, then calculate the Coinsurance (due from patient) and the Insurance Payment amount.
See my ‘Hints’ below!
Service
Charge
UCR
Copay
Coinsurance (Patient Payment)
Insurance Payment
Internal Medicine Physician Visit
$120.00
$120.00
Physical Therapy
$150.00
$97.00
Cardiologist Physician Visit
$165.00
$90.00
Chest X-ray
$115.00
$73.00
MRI Chest
$1,845.00
$1,147.00
Dermatology Physician Visit
$75.00
$70.00
Lab Test
$32.00
$19.00
Lab Test
$45.00
$29.00
Mammogram
$151.00
$95.00
Hints:
The Physician Visits have a $20 copay and the deductible has been met. Subtract the copay from the UCR billed amount then use the 80/20 distribution calculation to determine the coinsurance and the insurance payment.
The other procedures (non-physician visits) have 20% coinsurance (pays on the 80/20 distribution) so 20% of the UCR is coinsurance and since the deductible has been met the insurance pays the rest (the other 80%) of the UCR.
Any difference between the Charge and the UCR is written off because the UCR is the maximum amount the insurance company will allow.
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