Scenario 1: A Medicare patient is by the doctor in the office (outpatient visit)
ID: 328094 • Letter: S
Question
Scenario 1:
A Medicare patient is by the doctor in the office (outpatient visit).
The patient had already met his deductible for Medicare Part B. The coinsurance amount is 20%. The doctor’s charge for the visit is $300.
Medicare allowed amount for the PAR is $260 and $247 for the non-PAR
Answer the following questions showing your calculations (if applicable):
#1
a. If the PAR accepts assignment, the total amount of reimbursement to him will be $260.00
b. For the PAR who accepts assignment, the total amount that the patient is responsible for is
c. The patient is responsible for 20% which is the coinsurance amount?
d. If the non-PAR accepts assignment, the total amount of reimbursement to him is $
e. For a non-PAR who accepts assignment, the patient has to pay only the _________ amount which is $ ________
f. How much does the PAR write off and why?
g. How much does the non-PAR write-off and why?
Explanation / Answer
Answer: -
We would be answering first question-f and question-g as it would help to question-a to question-e.
Answer-f and Answer-g: -
PAR is participating provider and Non-Par is Non-Participating Provider are the providers who enroll in Medicare Program. A provider is said to be PAR who has enrolled and has accepted the assignment and is said to be Non-Par who has enrolled in Medicare but has not accepted the assignment.
As a PAR, provider is required to bill on an assignment basis and accept the Medicare Allowable Fee as a payment in Full. Medicare will accept 80% of the allowable amount and the patient would pay 20% co-insurance at the time services are rendered or when insurer ask to bill their Medicare Supplementary Policy.
The allowable amount is derived from:-
The allowable fee for Non-PAR is reduced by 5% as comparison to a PAR.
With this understanding we can answer the questions:-
Answer-a: Medicare allowed amount for PAR is $260, hence if PAR accepts the assignment the total amount of reimbursement to PAR is 80% of $260 which is $208.
Answer-b:- For the PAR who accepts assignment, the total amount that the patient is responsible for is calculated below:-
Doctor Charges = $300,
PAR allowable amount = $260
PAR would pay = $208
Hence, Patient need to pay $260 - $208 = $52.
Note: The remaining doctor fee which is $300 - $260 = $40 is required to be paid than it would $92
Answer-c:- The 20% co-insurance amount for PAR who accepts the assignment would be 20% of $260 is $52 and if Non-PAR has accepted the assignment then it would be 20% of $247 which is $49.4
Answer-d:- If the Non-PAR accepts the assignment the total amount of reimbursement to him is 80% of $247 which is $197.6
Answer-e For a Non-PAR who accepts the assignment the patient has to pay only 20% of amount which is $247 - $197.6 = $49.4. Note: The remaining doctor fee which is $300 - $247 = $53 is required to be paid than it would $102.4
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