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Understanding Medicare Medical Payment Schemes
By Staff Reporters
As of 1992, Medicare invoices are paid per resource-based relative value unit (RBRVU), and according to the lesser of the actual billed charges or the fee schedule amount. But, there are two types of medical providers: 1. Doctors who accept Medicare assignment only bill the patient for the co-payment, which is usually 20%. 2. Doctors who do not accept Medicare assignment are offered a lower fee schedule of 95% of the approved schedule, which is a 115% maximum fee limit of the approved schedule.
Example:
A participating physician’s approved fee schedule charge of $100 would yield $80 from Medicare and $20 from the patient. A non-participating (Non-Par) doctor with charges of $200, and with an approved fee schedule of $100, would yield: $109.25 = (.95 X $100) X 1.15 entirely from the patient.
If the Non-Par doctor selects payment type on a case-by-case basis, Medicare will pay its portion of the bill directly to the physician, but the doctor must accept the Non-Par fee schedule.
Assessment
Continuing our example yields: (.8 X $95) plus the patient’s co-payment of (.2 X $95), OR $76 plus $19 = $95.00.
Conclusion
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Filed under: Health Economics, Health Insurance, Healthcare Finance | Tagged: medicare, medicare providers, non-participating medicare physician, Participating medicare physician, RBRVU, resource-based relative value unit | 1 Comment »
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