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The Essential Question for Most Medical Providers
By Staff Reporters
Ever since 1992, doctors 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 providers.
- Those who accept Medicare assignment only bill the patient for the co-payment, which is usually 20%.
- Those 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.
So, how does this work in real life?
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: Healthcare Finance, Practice Management | Tagged: medicare, Non-Participating Physician, Participating Physician, RBRVU, resource-based relative value unit | 4 Comments »
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