Question

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

Answer 1

The Medicare Non-participating physician allowed amount is $427.50. Medicare payment for non-participating providers is $342. The Limiting charge to the patient is $491.63.

Step-by-step explanation:

The calculation for a non-participating provider who bills Medicare involves several steps to determine the Medicare Non-participating physician allowed amount, the Medicare payment, and the Limiting charge to the patient. These financial calculations rely on the predetermined rates that Medicare sets.

Medicare Non-participating physician allowed amount: The Medicare Participating Physician Fee Schedule Allowed Amount is $450. For a non-participating provider, we deduct 5 percent from this amount. Thus, the Non-participating Physician Allowed Amount is $450 - ($450 × 0.05) = $450 - $22.50 = $427.50.

Medicare payment: Medicare generally pays 80% of the allowed amount for participating providers. For a non-participating provider, this calculation is based on the reduced allowed amount. Therefore, the Medicare payment is 80% × $427.50 = $342.

Limiting charge to patient: The limiting charge is the maximum amount a non-participating provider can legally charge a Medicare beneficiary. This is calculated by taking the Non-participating Physician Fee Schedule (MPFS) allowed amount, minus 5 percent, which we have already calculated as $427.50, and then multiplying it by 115 percent. This gives us the limiting charge: $427.50 × 1.15 = $491.63.