Health Insurance Calculations – Medicare Non-Participating Provider
This scenario is for a non-participating provider who contracts with Medicare. Prior to determining the limiting charge, you must first decrease the PFS amount by 5%. More information is available to you in Chapter 9 of your text, pages 322-330. Specific tips are:
· Non-participating Medicare physician receives a 5% reduction of the MPFS
· Limiting charge = the highest amount the provider can collect from the patient and insurance
· Limiting charge = [MPFS – (5% x MPFS)] x 115%
Analyze a scenario to determine monetary responsibility for a visit.
Scenario
Calculate the following amounts for a non-participating provider who bills Medicare.
Submitted charge (based on provider’s regular fee) = $650
Medicare participating physician fee schedule allowed amount = $450
Medicare Non-participating physicians allowed amount = $
(MPFS allowed amount, less than 5 percent)
Medicare payment (80% of MPFS allowed, less 5 percent)= $
Limiting charge to patient = $
[MPFS – (MPFS x 5 percent)] x 115 percent
Patient payment = $
(balance of the limiting charge minus Medicare payment)
Provider write-off = $
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