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

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·         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)

Provider write-off                                                                                $     

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