HP214B Reimbursement Methodologies – Week 5 Assignment 1 Health Insurance Calculations – Medicare Participating Provider Please review the lecture information prior to completing this task. This scenario is for a provider who contracts with Medicare. More information is available to you on pages 322-330 of your text. Specific tips are: · Participating provider receives the full amount listed on the Medicare Physician’s Fee Schedule (MPFS or PFS). · The copay may be paid by the patient or supplemental insurance. Analyze a scenario to determine monetary responsibility for a visit. · Calculate the figures for each category under both scenarios. Scenario 1A Calculate the following amounts for a participating provider who bills Medicare and has no deductible left. Submitted charge (based on provider’s regular fee) $650 Medicare participating physician fee schedule (PFS) $450 Coinsurance amount (20% paid by) $ Medicare payment (80 percent of the PFS) $ Provider write-off $ Scenario 1B Calculate the following amounts for a participating provider who bills Medicare and remaining annual deductible for the patient. Submitted charge (based on provider’s regular fee) $650 Medicare participating physician fee schedule (PFS) $450 Patient pays $100 remaining on their deductible $ Remaining amount for Insurance and patient to pay $ (PFS – $100) Coinsurance amount (20% of remaining amount) $ Total paid by patient (deductible & 20% of remaining) $ Medicare payment (80 percent of the remaining amount) $ Provider write-off $
