Fam Pract Manag. 2003;10(8):73-74
Medicare participation
EXAMPLE: A $100 MEDICARE FEE SCHEDULE SERVICE
| Payment arrangement | Total payment rate | Payment amount from Medicare | Payment amount from the patient |
|---|---|---|---|
| Participating physician | 100 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 claim | 95 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 claim | 115 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 |