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 = $