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).

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·         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                                                                    $      

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