Topic: CMS Reimbursement Methodologies

Chapter 9 includes information about CMS's reimbursement systems. As you read this chapter, you will see there are many terms and related issues associated with this reimbursement system.

The healthcare programs that are administered by the federal government have a payment system that includes a predetermined reimbursement methodology.

Part of this system includes PAR and nonPAR physician charges.

1. In your initial post, explain how reimbursement differs between PAR and nonPar charges.

Also include your answer to number 1 and number 2 of the Chapter Review on page 371 of the Green & Rowell text in your initial post:

1. Calculate the following amounts for a PAR who bills Medicare:

Submitted charge (based on provider's regular fee for office visit)is $75

Medicare physician fee schedule (PFS) is $60

Coinsurance amount (paid by patient or supplemental insurance) is $12

Medicare payment (80% of the allowed amount is? ______

Medicare write-off (not to be paid by Medicare or the beneficiary? ____

2. Calculate the following amounts for a nonPar who bills Medicare:

Submitted charge (based on provider's regular fee) is $650

NonPAR Medicare physician fee schedule allow payment is $450

Limiting charge (115% of MPFS allowed amount) is?______

Medicare payment (80% of the MPFS allowed amount) is? ____

Beneficiary is billed the balance of the limiting charge $149.63

The Medicare write-off (not to be paid by Medicare of the beneficiary) is?____

2. Discuss how you determined your answers.