Medicare NP Payment Calculations
Health Insurance Calculations – Medicare Non-Physician Provider
Please review the lecture information prior to completing this task. This scenario is for a non-physician provider, such as an N.P. or P.A., who contracts with Medicare.
Use the attached document to complete
WK8 INFO HP-214
Health Insurance Calculations – Medicare Non-Physician Provider
Please review the lecture information prior to completing this task. This scenario is for a non-physician provider, such as an N.P. or P.A., who contracts with Medicare. More information is available to you in Chapter 9 of your text.
Analyze a scenario to determine monetary responsibility for a visit.
Fill in the blanks in the following payment situations:
Scenario 1
Calculate the following amounts for an NP who bills Medicare as an incident to a supervising physician (billed under the physician’s NPI).
Submitted charge $75
Medicare allowed amount (MPFS) $60
Nurse practitioner allowed amount (100% of MPFS) $
Medicare payment (80 percent of the allowed amount) $
Coinsurance amount (20% allowed amount) $
Provider write-off $
Scenario 2
Calculate the following amounts for an NP who bills Medicare under their own NPI.
Submitted charge $75
Medicare allowed amount (MPFS) $60
Nurse practitioner allowed amount $
(80% of office charge or 85% of MPFS whichever is lower)
Medicare payment (80% of the allowed amount) $
Coinsurance amount $
Provider write-off $ Medicare NP Payment Calculations
-
For Scenario 1, what is the nurse practitioner allowed amount (100% of MPFS)?,
-
What is the Medicare payment (80% of the allowed amount) for Scenario 1?,
-
What is the coinsurance amount (20% of allowed amount) for Scenario 1?,
-
What is the provider write-off for Scenario 1?,
-
For Scenario 2, what is the nurse practitioner allowed amount (80% of office charge or 85% of MPFS, whichever is lower)?,
-
What is the Medicare payment (80% of the allowed amount) for Scenario 2?,
-
What is the coinsurance amount for Scenario 2?,
-
What is the provider write-off for Scenario 2?,
-
How do the calculations differ when billing “incident to” versus under the NP’s own NPI?,
-
How do these calculations affect patient responsibility and provider reimbursement?
Comprehensive General Answer
Scenario 1 – NP Billed “Incident to” Physician
-
Submitted charge: $75
-
Medicare allowed amount (MPFS): $60
-
Nurse practitioner allowed amount (100% of MPFS): $60
-
Medicare payment (80% of allowed amount): 0.8 × $60 = $48
-
Coinsurance amount (20% of allowed amount): 0.2 × $60 = $12
-
Provider write-off: Submitted charge − allowed amount = $75 − $60 = $15
Explanation: When billing “incident to,” the NP is reimbursed at 100% of the MPFS. Medicare pays 80% of the allowed amount, the patient is responsible for the remaining 20%, and the provider cannot collect the difference between the submitted charge and the allowed amount (write-off).
Scenario 2 – NP Billed Under Own NPI
-
Submitted charge: $75
-
Medicare allowed amount (MPFS): $60
-
Nurse practitioner allowed amount (80% of office charge or 85% of
The post Medicare NP Payment Calculations appeared first on Assignment Help Central.