This scenario is for a 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. Scenario 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 $ SCIENCE HEALTH SCIENCE NURSING HP 214

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