Sunday, September 19, 2010

Medicare reimbursement basic questions - provider accept assignment

When I see my doctor, must I pay first and then get Medicare to reimburse me?


It depends on your doctor and on whether your doctor accepts assignment.

If your doctor accepts assignment:
 
He or she can only ask you to pay the 20 percent coinsurance (45 percent for mental health services) up front (and your Part B deductible if you have not yet reached it—$155 in 2010). Your doctor files the claims, and Medicare pays the doctor directly.

If your doctor does NOT accept assignment:
 
Your doctor may ask you to pay the full amount for services in advance and charge you up to 15 percent more than Medicare’s approved amount under federal law. Some states have stricter limits on what your doctor can charge you. See the MI Extra to find out what percent of the Medicare-approved amount a non-participating provider may charge you in your state in addition to the Medicare coinsurance.

Medicare will reimburse you directly for its part of the bill (80 percent of Medicare's approved amount for most medical services; 55 percent for mental health services).

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Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download