Anon-participating provider is legally allowed to make a decision on agiven claim on either to reject or accept assignment oralternatively, bill the patient under unassigned basis. Therefore, inour case, the legal non-participating provider fee allowed isdecreased by five percent, when compared to a provider whoparticipate. As a result, the allowed fee for no-participating inthis case would be $95. The Medicare will have to pay 80% of the $95.In case the assignment was accepted, the patient would have paid 20%of the $95. However, if the assignment was not accepted, the patientwould have paid out of pocket for the service. When comes to suchscenario, the maximum charge a provider is allowed to charge apatient is 115%, which is also known as a limiting fee. As a result,the fee will be calculated as follows: 115% x $95 = $109.25. On otherhand, Medicare normally has two billings portion. The first one(hospital insurance) is to compensate for inpatient services ofhospital, while the second one is to (medical insurance) compensatefor clinic services, outpatient hospital services as well as doctorfees. In our scenario, if the Medicare accepts 80% ($80), then thepatient will pay 20% ($20+9.25= $29.25).
Itis worth noting that, all the claims for unassigned non-participatingproviders are reviewed in order to make sure they comply with thelaw, which limits them from overcharging.
Howdo a high percentage of Medicaid (not Medicare) patients influence ahospital’s prices?
Asnoted by Cleverley, Song & Cleverley (2010), Medicaid normallydon’t pay hospital charges, rather pays hospitals as per the legalstipulated diem rate, which is similar to a huge discount fromhospital billed charges. As a result, considering an increment ofMedicaid, the hospital bill will definitely shoots up in order tocompensate the deficit emerging from Medicaid small paymentreimbursements.
Cleverley,Song & Cleverley, (2010). Essentialsof Health Care Finance (7th ed). Jones and Bartlett Learning