Paying for Physician Services

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It is stated that successful health reform is focused on Medicare and Medicaid innovations (Guterman et al., 2010).  Accordingly, the Centers for Medicare and Medicaid Services, or CMS, aim to develop innovative payment and delivery system for processing claims. In light of this, doctors need to be aware of the CMS participation in receiving payments from the clients.  Most clients who have availed of Medicare will make reimbursement claims for themselves and some payments are coursed through Medicare and the patient.  Accordingly, the CMS has provided physicians different options for opting in or out of Medicare payments and reimbursements (AMA, 2010).      

The Medical Payment Advisory Commission or MEDPAC together with CMS (CMS, 2010) states that payment rates are based on work required for a service, expenses incurred for professional practice, and insurance costs and liabilities.

Payment for Medicare Participating Physicians

For the first question, Medicare reimburses $5,701.80, which is 80% of total fees.  Mr. Smith will pay $1,425.45 Dr. Johnson out of his own pocket.  This calculation is based on the formula:

Conversion Factor x (Product of RVU and GCI + Product of Practice Expense RVU + GCI + Product of Malpractice RVU and GCI). 

Physician’s fee is 80% of the allowed Medicare fee to be paid by the Medicare while 20% of the allowed Medicare fee is the amount payable by the client.

It is calculated as follows: 64.43 (29.98+75.04+5.6) = $7,127.25.  The Medicare pays physician 80% from the total fee, which is calculated as: $7,127.25 x .8 = $5,701.80.  Therefore, Mr. Smith will pay from his own money an amount equivalent to 20% of the total fee, which is calculated as follows: $7,127.25 x .2 = $1,425.45.

The American Medical Association (2010) states, that participating physicians will receive an amount equivalent to 80% for their claimed assignments from the Medicare association and the 20% from the client.  It is further stated that physicians have the responsibility to send the 20% bill to the client but the amount must not exceed the allowance required by Medicare. 

Paying for Non-Medicare Participating Physicians

Approved Medicare fees for non-participating physicians are 95% of the approved amount for participating physicians.  There is also a 9.25% limiting charge above participating physicians for services rendered to the clients. Moreover, the amount paid by Medicare is still at 80% of the 95% amount to be billed, the remaining 20% will be paid by the client (AMA, 2010). 

AMA (2010) further states that the 95% rate for payment is based on the physician’s status as participating or non-participating and not on whether the physician accepts assignments on a claim or not. 

The questions cited in number two pertain to the first and second options provided for the physician. Full payment is given the client if the doctor does not accept the assignment wherein Medicare will reimburse payment based on its calculated share of the bill.  Nonetheless, CMS (2010) states that Medicare has set a limiting charge of 15% or 95% of Medicare approved payments, and that no client is required to pay more than 9.25% over 100%.  Patients will pay 20% to physicians if the physician’s status is either participating physician or non-participating with assignment claimed.  For non-participating physicians with assigned claims, 80% is paid by the Medicare group to the patient and the patient is responsible for paying the physician for the full amount which includes Medicare’s 80% plus patient’s 20% plus 14.25 remaining balance (CMS, 2010; AMA, 2010).

For the second question wherein Dr. Johnson is a Medicare non-participating physician, total payment rate is 95% of Medicare approved fees of participating physicians, therefore it is calculated as: 95% x $7,127.25 = $6,770.88, wherein 80% of this amount will be from the Medicare group that calculates to an amount of $5,416.71 and the remaining 20% will be paid outright by the patient which amounts to 20%.  It is calculated as follows: $6,770.88 x .20 = $1,354.18.

For the third question, since the physician opts to take an unassigned claim, Medicare is required to pay the patient directly instead of the physician even if physician would submit claim forms for the said services (CMS, 2010).  There is a limiting charge of 115% of the 95% allowance granted to non-participating physicians (CMS, 2010).

The CMS (2010) provides the explanation for the following statements that provides the answers for the third question.  Accordingly, the patient, Mr. Smith will have to pay the physician the full amount of $7,786.52.  Either the patient or the physician will file for reimbursements with Medicare.  Therefore, Medicare reimburses Mr. Smith the amount of $5,416.71, which is 80% of the 95% allowable for non-participating doctors who elects assignment.  Mr. Smith in turn will pay Dr. Johnson the amount $1, 557.30 from his own money. Medicare pays $812.51 to the physician, which is 80% of the 115% rate of the approved amount.   

The above mentioned sums are calculated as follows: Medicare approved amount for non-participants is .80 x $6,770.88 = $5,416.71.  Medicare plan calculated benefits: 115% x $6,770.88 = $7,786.52 X 80% = $6,229.21.  Medicare plan payment to physician is calculated plan benefit – approved amount. Therefore, $6,229.21 - $5,416.71 = $812.51.  Medicare reimbursement to the patient: $7,127.25 x .95 = $6,770.88 x .80 = $5,416.71.

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