Medicare Reimbursement This Assignment Will Test Your Knowle

Medicare Reimbursementthis Assignment Will Test Your Knowledge Of Reim

This assignment will test your knowledge of the reimbursement methods of the Medicare program. It involves five scenarios related to the reimbursement of services provided to patients enrolled in Medicare. You are required to analyze each scenario carefully, considering details such as whether the provider accepts Medicare and the charges involved. Use Chapter 9 (starting on page 322 of the textbook) to assist with calculations of reimbursement. Be sure to show your work for each scenario.

Paper For Above instruction

Medicare reimbursement procedures are complex and depend significantly on whether providers are participating or non-participating in the Program, as well as on the charges submitted and the Medicare Physician Fee Schedule (MPFS). This paper examines five scenarios, analyzing the reimbursement process in each case to understand how payments are determined under Medicare regulations.

Scenario 1: Mr. Allgood’s Procedure at Meadowview Medical Center

Mr. Allgood was discharged after a procedure on his left leg. His Medicare coverage was accepted by Meadowview, a participating provider. The provider billed $215, while the MPFS for the procedure was $150. Since Meadowview is a participating provider, Medicare agrees to pay the approved amount listed in the fee schedule, provided it is within the allowed limits. The difference between the billed amount and the MPFS fee is irrelevant here because participating providers agree to accept the Medicare-approved amount as full payment.

Therefore, Medicare administers payment based on the MPFS fee of $150. As Meadowview is a participating provider, it cannot charge more than this amount. Medicare will pay $150 for the procedure, and Mr. Allgood is responsible for any deductible or coinsurance applicable, though these are not specified here. This scenario exemplifies the typical fee-for-service reimbursement for participating providers, where reliance on the MPFS ensures standardized payment amounts.

Scenario 2: Mrs. Holloway’s Outpatient Surgery Billing

Mrs. Holloway received outpatient surgery at Oceanside Surgery Center, which accepts Medicare assignment. The center charged her $1,000, and the MPFS for her procedure is $917. She was billed $200, which raises questions about billing accuracy.

Since Oceanside accepts Medicare assignment, it is obligated to accept the Medicare-approved amount, which is $917. The patient’s bill should reflect the Medicare-approved amount or less, adjusted by her coinsurance or deductible. Billing her $200 is within reason if it reflects her coinsurance, but her total obligation should not exceed the coinsurance amount corresponding to the Medicare payment.

If the standard coinsurance rate is 20%, then her coinsurance portion on $917 would be approximately $183.40. Since she was billed only $200, she has been billed slightly above her expected coinsurance, which may suggest billing errors or willingness on the provider’s part to charge extra fees. However, the key point is that the provider cannot bill her more than the Medicare-approved amount ($917) plus any allowed coinsurance. Thus, her billing appears reasonable if $200 represents her coinsurance, but the final bill may need reevaluation to ensure it aligns with Medicare policies.

Scenario 3: Mr. Tee’s Procedure with a Non-Participating Provider

Mr. Tee, a Medicare patient, wants a provider who does not accept assignment, i.e., a non-participating provider. The MPFS for the lower back procedure is $849. Because the provider does not accept Medicare assignment, Medicare only pays a limiting charge, which is typically 115% of the MPFS for non-participating providers.

Calculating the limiting charge: 115% of $849 equals approximately $975. This is the maximum amount Medicare will consider for reimbursement. The provider, however, can bill the patient the entire charge of $849 and collect from the patient. Medicare’s responsibility is limited to the limiting charge of $975, but since the provider does not accept assignment, the provider will bill Mr. Tee the full amount.

Mr. Tee’s responsibility depends on what the provider charges. If the provider bills $849, he is responsible for paying this amount in full. Medicare will not pay anything directly to the provider because the provider does not accept assignment. Instead, Mr. Tee pays the entire bill, and Medicare may reimburse him afterward if he files a claim and meets the criteria. The key point here is that without assignment, Medicare’s role is limited, and the patient is responsible for the full charge.

Scenario 4: Ms. Poppins’s Treatment at a Participating Provider

Ms. Poppins received treatment from New Scenery Medical Group, which accepts Medicare. The group charged $73, and the MPFS for her treatment is $70. She is responsible for paying $14, which suggests her coinsurance and deductible contributions. The question is how much the provider can write off as uncollectible.

Since the allowable charge is the Medicare-approved amount of $70, and Ms. Poppins’s responsibility is $14, it indicates she paid part of her coinsurance. The difference between the charges ($73) and the Medicare-approved amount ($70) is $3, which can be written off as an overcharge or uncollectible amount if the provider billed incorrectly or if the excess charges are considered uncollectible.

In this case, the total uncollectible amount that the provider can write off is the excess over the Medicare-approved amount not paid by the patient, which is $3. This ensures the provider adheres to Medicare’s guidelines for billing and collections, preventing overcharging and maintaining compliance with program rules.

Scenario 5: Mr. Rogers’s Non-Participating Service

Mr. Rogers received medical services from Uptownship Healthcare for abdominal pain. The provider charges $750, but does not accept Medicare assignment. The MPFS for this service is $615. The limiting charge, Medicare’s portion, the patient’s obligation, and potential write-offs are to be determined.

For non-participating providers, the limiting charge is typically 115% of the MPFS. Calculating this: 115% of $615 is approximately $707.25, which is the maximum amount Medicare will consider for reimbursement.

The provider can bill Mr. Rogers up to this limiting charge amount, which is $707.25. Since the provider’s actual charge is $750, Mr. Rogers can be billed only up to $707.25 as the limiting charge. The Medicare’s portion of the payment is $615 (the MPFS), and Medicare will pay that amount directly. Mr. Rogers is responsible for the difference between the limiting charge ($707.25) and Medicare’s payment ($615), which amounts to $92.25, representing his coinsurance or deductible responsibility.

The provider can write off the difference between their billed amount ($750) and the limiting charge ($707.25), which is $42.75. This amount is uncollectible because the provider cannot exceed the limiting charge set by Medicare’s regulations.

Conclusion

These scenarios illustrate the importance of understanding the distinctions between participating and non-participating providers, the application of the Medicare Physician Fee Schedule, and the calculations involved in determining the payment responsibilities of both Medicare and patients. Proper knowledge of these processes ensures compliance with Medicare rules and helps avoid billing errors, ultimately facilitating appropriate reimbursement and patient billing practices.

References

  • American Medical Association. (2020). Medicare Physician Fee Schedule. AMA CPT Professional Edition.
  • Centers for Medicare & Medicaid Services. (2023). Medicare Billing and Coding. CMS.gov.
  • Kaiser Family Foundation. (2022). An Overview of Medicare Payment Policies. KFF.org.
  • Schneider, E. C., et al. (2019). “Understanding Medicare and Reimbursement Systems.” Journal of Healthcare Management, 64(3), 197-209.
  • Starr, P. (2017). “The Politics of Medicare.” The New England Journal of Medicine, 376(11), 1074-1076.
  • Himmelstein, D. U., & Woolhandler, S. (2016). “The High Cost and Hardship of Medical Bills Median and average amounts and repayment methods.” American Journal of Medicine, 129(4), 377-381.
  • Smith, S. (2021). “Medicare Part B Billing and Reimbursement.” Medical Economics, 98(10), 23-27.
  • United States Department of Health & Human Services. (2022). Medicare Program Overview. HHS.gov.
  • Xu, J., et al. (2020). “Billing Practices and Cost Containment in Medicare.” Health Affairs, 39(3), 456-463.
  • Garrett, M. (2018). “Reimbursement Strategies for Medicare Providers.” Healthcare Financial Management, 72(4), 34-39.

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