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Calculate the following amounts for a nonpar who bills medicare

03/04/2021 Client: muhammad11 Deadline: 2 Day

I need help with a Health & Medical question. All explanations and answers will be used to help me learn.

AH 120 Calculating Reimbursement Methodologies

Using the Medicare Physician Fee Schedule, there are different methods to calculate the reimbursement for participating providers and non-participating providers.

Under Medicare, participating providers are reimbursed at 80% of the fee schedule amount. To calculate the reimbursement, use the following formula:

MPFS amount x 80% = This is the allowed charge.

The patient is responsible 20% of the MPFS amount, and a participating provider will accept the MPFS amount as payment in full, regardless of what he charged. The difference between the MPFS amount and the physicians charge is called a write off.

Reimbursement for non-participating providers (non-pars) is more complex.

Below are the steps for calculating the non-par reimbursement

Non-pars are reimbursed 5% less than the Medicare Physician Fee Schedule (MPFS) amount.
The non-pars may not charge the patient more than what is called the limiting charge. The limiting charge is 115% of the reduced MPFS amount.
The formula for calculating the limiting charge is :
[MPFS – (MPFS x 5%)] x 115% = limiting charge

Medicare will reimburse the non-par 80% of the reduced amount
Non-pars do not accept the MPFS amount as payment in full and may charge the patient for the difference between the limiting charge and the MPFS amount

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