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Fam Pract Manag. 2003;10(8):73-74

Medicare participation

EXAMPLE: A $100 MEDICARE FEE SCHEDULE SERVICE

Payment arrangementTotal payment ratePayment amount from MedicarePayment amount from the patient
Participating physician100 percent Medicare fee schedule = $100$80 (80 percent) paid by carrier to physician$20 (20 percent) paid by patient or supplemental insurance (i.e., Medigap)
Nonparticipating physician/assigned claim95 percent Medicare fee schedule = $95$76 (80 percent) paid by carrier to physician$19 (20 percent) paid by patient or supplemental insurance
Nonparticipating physician/unassigned claim115 percent of $95 (Medicare’s “limiting charge”) = $109.25$0$76 (80 percent) paid by carrier to patient
$19 (20 percent) paid by patient or supplemental insurance
$14.25 balance bill paid by patient

HIPAA and homework

Tracking performance

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