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Cristina Thibeault Discussion 

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1.  In your initial post, explain how reimbursement differs between PAR and nonPar charges.

NonPar “ Nonparticipating Providers is when a patient goes to an out of network/nonparticipating  doctors office and they have no set contract with the physician and the insurance company.  The patient is usually expected to pay the difference between the insurance payment and the providers fee.

Par “Participating Providers” is when there is a contract involved with the health insurance plan and accepts whatever the plan pays for the procedures or services performed. Participating providers are not allowed to bill patients for the difference between the contracted rate and their normal fee. (Green & Rowell, 2017) 

Question 1: Calculate the following amounts for a PAR who bills Medicare:

-Submitted charge (based on provider’s regular fee for office visit) is $75
-Medicare physician fee schedule (PFS) is $60
-Coinsurance amount (paid by patient or supplemental insurance) is $12

-Medicare payment (80% of the allowed amount is?  $48

-Medicare write-off (not to be paid by Medicare or the beneficiary?  $15

Question 2: Calculate the following amounts for a nonPar who bills Medicare:

-Submitted charge (based on provider’s regular fee) is $650
-NonPAR Medicare physician fee schedule allow payment is $450

-Limiting charge (115% of MPFS allowed amount) is? $491.63

-Medicare payment (80% of the MPFS allowed amount) is?  $342

-Beneficiary is billed the balance of the limiting charge $149.63

-The Medicare write-off (not to be paid by Medicare of the beneficiary) is? $158.37

Explanation:

The charge based on provider was $650.00 and the nonPar MPFS allowed amount was $450.00. The limiting MPFS 450-(450X5%)X115%, so 427.50 X 115% gives you  $491.63 Now you get the $427.50 multiply that by the 80% and you get the $342.00. Now the final step is getting the $650.00 of the submitted charge and subtracting it from the limiting charge of $491.63 gives you $158.37 the Medicare write-off amount,

Reference:

Green, M. & Rowell, J. Understanding Health Insurance A Guide to Billing and Reimbursement (p.371)  13th Edition Delmar Cengage Learning

post 2

 Kelsey Choate Week 3 DiscussionCOLLAPSE

Cuppett explains that nonparticipating providers (nonPARs) can submit claim-by-claim assignments, while participating providers (PARs) “have an agreement with Medicare to ‘accept assignment’ on all Medicare claims.” According to Green & Rowell, nonPARs cannot charge the Medicare beneficiary more than difference between what Medicare reimburses and the limiting charge and can only report the limiting charge as their fee. Green & Rowell also report that PARs report their actual fees to Medicare but adjust the uncollectable charge when they receive payment.

1. Calculate the following amounts for a PAR who bills Medicare:

Medicare payment (80% of the allowed amount) is?

                             (MPFS x 80%)

                             $60 x 80%

$48

Medicare write-off (not to be paid by Medicare or the beneficiary)?

                             (submitted charge – MPFS)

                                           $75 – $60

$15

2. Calculate the following amounts for a nonPar who bills Medicare:

Limiting charge (115% of MPFS allowed amount) is?

[MPFS – (MPFS x 5%) ] x 115%

[ $450 – ($450 x 5%) ] x 115%

              [$427.50] x 115%

$491.63

Medicare payment (80% of the MPFS allowed amount) is?

              (MPFS x 80%)

              $427.50 x 80%

$342.00

3. Beneficiary is billed the balance of the limiting charge $149.63

The Medicare write-off (not to be paid by Medicare of the beneficiary) is?

                             (submitted charge – limiting charge)

                                           $650 – $491.63

$158.37

References:

 Cuppett, T. (2010). Medicare PAR vs. NonPAR guidelines. Retrieved from https://www.aapc.com/blog/5944-medicare-par-vs-nonpar-guidelines/

Green, M. & Rowell, J. (2017). Understanding health insurance: A guide to billing and reimbursement. Boston, MA: Cengage Learning

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