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 provider can collect from patient and insurance
· Limiting charge = [MPFS – (5% x MPFS)] x 115%
Analyze a scenario to determine monetary responsibility for a visit.
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 physician allowed amount $
(MPFS allowed amount, less 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)