APA respone to the answers of these questions. 200 word cited
1. A non-participating physician provides services to a Medicare patient who has total charges of $100 (before Medicare’s limiting charge is applied). The physician does not accept assignment, charges the maximum allowable, and submits the claim to Medicare. Assume Medicare’s approved schedule for these services is $80.
What is the maximum amount the physician is allowed to charge the patient? Since this is a non-participating physician, he/she is only “allowed to charge 95% of the approved fee schedule” (Cleverley & Cleverley, 2018), in this case the approved fee schedule is $80, by multiplying 0.95 x $80 we will get $76, take this times the max factor of 115% and we get $87.40, which is what can be charged to the patient.
What is the Medicare portion of the physician payment (which Medicare sends to the patient)? Medicare will pay 80% of the allowed fee schedule, and because in this case the provider is non-participating, Medicare will pay $69.92. $87.40 x 0.80
What is the patient’s portion of the payment to the physician (net of the reimbursement from Medicare in the previous question)? The patient’s potion of this will be $19 because this provider is non-participating, the patient will only have to pay 95% also. The patients co-pay is $20 so we take 0.20 x $87.40, which gives us the $17.48, which is the patient’s portion.
Would the physician have been better off by accepting assignment on this case? Why or why not? In this case the provider made $7.40 more then they would have if they just accepted assignment, so I believe that the physician was better off not taking the assignment.
2. How do a high percentage of Medicaid (not Medicare) patients influence a hospital’s prices? A high percentage of Medicaid patients may influence a hospital’s prices but most times not. “In Medicaid, payment rates, sometimes called the “base rate,” are set by state Medicaid agencies for specific services used by patients. In addition, Medicaid also may make supplemental payments to hospitals.” (Cunningham, Rudowitz, Young, Garfield, and Foutz, 2016) So, hospitals will have their prices, but because Medicaid payment amounts are set by the state, the hospital may or may not be paid their price, depending on what amount the state has set. If a hospital has a high percentage of Medicaid patients they may lower their costs, if they can afford to do so, or they may raise their cost to the other then Medicaid patients to try and make up the difference.
Cunningham, P., Rudowitz, R., Young, K., Garfield, R., & Foutz, J. (2016, October 27). Understanding Medical Hospital Payments and the Impact of Recent Policy Changes – Issue Brief. Retrieved from https:// www.kff.org/report-section/understanding-medicaid-hospital-payments-and-the-impact-of-recent-policy-changes-issue-brief/
Cleverley, W. O., & Cleverley, J. O. (2018). Essentials of health care finance. Burlington, MA: Jones & Bartlett Learnin.