Questions and Answers
What is a Medicare Participating Provider allowed to do with the fee schedule?
What is the primary disadvantage for Non-Participating Providers?
What can Non-Participating Providers charge above Medicare's approved amount?
What is the 'Limiting Charge' in Medicare reimbursement?
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How is the 20% coinsurance for a Participating Provider calculated?
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What happens to amounts billed above the limiting charge for covered services?
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How much does a Non-Participating Provider charge a patient beyond Medicare's covered amount for a 92004 procedure?
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What percentage of the reimbursement amount does Medicare pay to Non-Participating Providers?
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What is the primary function of the Limiting Charge for Non-Participating Providers?
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If a Non-Participating Provider performs a 92004 procedure with a reimbursement of $129.65, what is the patient responsible for paying in total?
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Study Notes
Private-Pay Patients
- Private-pay patients save practices time and costs related to benefit research, claims filing, reimbursement, and payment posting.
- A prompt-pay discount can be offered, but it should not exceed a 20% reduction.
- Discounts should also be available to insurers willing to pay immediately.
Insurance Payments and Reimbursement
- Creating an Excel chart of common CPT codes and their payments from various payers is beneficial for periodic evaluation.
- Accepting an insurance plan means agreeing to its payment terms and fee schedule.
- In the U.S., there are twelve regional Medicare Administrative Contractors (MACs) with varying fee schedules by region.
- The Federal CMS Physician Fee Schedule lookup tool is essential for researching reimbursements across different CPT codes and regions.
Fee Settings
- Setting fees involves understanding practice overhead, financial demographics, and desired patient volume for income.
- Fees should not be excessively high or low to avoid deterring patients or struggling to break even.
- All patients should be charged the same fee per code, referred to as the “usual and customary fee.”
- It is essential not to differentiate fees based on insurance status; a specific code must have a uniform charge.
Medicare Participation
- Optometry offices are typically not classified as Medicare facilities, leading to the choice of non-facility fees for reimbursement.
- Accepting Medicare requires adherence to its fee schedule, designating providers as either “Medicare Participating Providers” or “Non-Participating Providers.”
- Participating Providers receive full reimbursement from Medicare, while Non-Participating Providers receive 95% and can bill patients for the excess up to a "limiting charge."
Limiting Charge
- The Limiting Charge for Non-Participating Providers is 15% above what Medicare pays Participating Providers.
- Patients are not accountable for any billed amounts exceeding the Limiting Charge for covered services.
Comparison of Provider Types
- Example comparison between Doctor A (Participating Provider) and Doctor B (Non-Participating Provider) reveals differing reimbursements:
- Doctor A receives a higher payment with lower patient out-of-pocket costs.
- Doctor B has higher reimbursement but incurs administrative burdens and potential patient dissatisfaction due to additional charges not covered by Medicare.
Implications of Fee Selection
- Setting excessively high fees can lead to patient backlash upon receiving their Explanation of Benefits (EOB), creating customer service challenges.
- The example highlights that optimal fee setting should consider both operational sustainability and patient access to services.
Private-Pay Patients
- Private-pay patients save practices time and costs related to benefit research, claims filing, reimbursement, and payment posting.
- A prompt-pay discount can be offered, but it should not exceed a 20% reduction.
- Discounts should also be available to insurers willing to pay immediately.
Insurance Payments and Reimbursement
- Creating an Excel chart of common CPT codes and their payments from various payers is beneficial for periodic evaluation.
- Accepting an insurance plan means agreeing to its payment terms and fee schedule.
- In the U.S., there are twelve regional Medicare Administrative Contractors (MACs) with varying fee schedules by region.
- The Federal CMS Physician Fee Schedule lookup tool is essential for researching reimbursements across different CPT codes and regions.
Fee Settings
- Setting fees involves understanding practice overhead, financial demographics, and desired patient volume for income.
- Fees should not be excessively high or low to avoid deterring patients or struggling to break even.
- All patients should be charged the same fee per code, referred to as the “usual and customary fee.”
- It is essential not to differentiate fees based on insurance status; a specific code must have a uniform charge.
Medicare Participation
- Optometry offices are typically not classified as Medicare facilities, leading to the choice of non-facility fees for reimbursement.
- Accepting Medicare requires adherence to its fee schedule, designating providers as either “Medicare Participating Providers” or “Non-Participating Providers.”
- Participating Providers receive full reimbursement from Medicare, while Non-Participating Providers receive 95% and can bill patients for the excess up to a "limiting charge."
Limiting Charge
- The Limiting Charge for Non-Participating Providers is 15% above what Medicare pays Participating Providers.
- Patients are not accountable for any billed amounts exceeding the Limiting Charge for covered services.
Comparison of Provider Types
- Example comparison between Doctor A (Participating Provider) and Doctor B (Non-Participating Provider) reveals differing reimbursements:
- Doctor A receives a higher payment with lower patient out-of-pocket costs.
- Doctor B has higher reimbursement but incurs administrative burdens and potential patient dissatisfaction due to additional charges not covered by Medicare.
Implications of Fee Selection
- Setting excessively high fees can lead to patient backlash upon receiving their Explanation of Benefits (EOB), creating customer service challenges.
- The example highlights that optimal fee setting should consider both operational sustainability and patient access to services.
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Description
Explore the benefits and implications of private-pay or self-pay options in healthcare practices. Understand the concept of prompt-pay discounts and how it affects both patients and insurers. This quiz will help you navigate financial decisions in healthcare management.