1. Instructor: Laurie Amdur, CPAR, CFC, PAS

4.  Room types—Medical, Surgical, ICU, & Intermediate ICU  Authorized vs. Charged  Payment for outside services— radiologists, physicians, pathologists, anesthesiologists, etc

5.  Patient in ICU 5 days and medical room 1 day  Authorized 3 ICU days and 3 medical rooms  $5000.00 deductible/$0.00 met, 80/20 coins  How much do we collect from the patient?

6.  Calculation for Medical ◦ $1000.00 X 3 = $3000.00  Calculation for ICU ◦ $2000.00 X 3 = $6000.00  Total amount Allowed (ICU + Medical) ◦ $3000.00 + 6000.00 = $9000.00

7.  Deductible = $5000  Coins calculation ◦ 20% X $9000.00 = $1800.00  Total to collect ◦ $5000.00 + $1800.00 = $6800.00

8.  $3000.00 deductible, $100.00/day Inpatient copay, 70/30 coinsurance, max out of pocket $5000.00  How much do we collect?

9.  Calculation for Medical ◦ $1200/day x 3 days = $3600  Calculation for ICU ◦ $2000/day x 3 days = $6000  Total Allowed ◦ $3600.00 + 6000.00 = $9600.00

10.  $3000.00 deductible  $100.00 copay per day ◦ 6 X $100.00 = $600.00  Coinsurance Calculation ◦ 30% X $9600.00 = $2880.00  Maximum OOP is $5000.00  Collect $5600.00 ($5000.00 + $600.00)

11.  $2500.00 deductible, then 100%  How much do we collect?

12. AMOUNT ALLOWED  Medical ◦ $900/day x 3 days = $2700  ICU ◦ $1500/day x 3 days = $4500  Total Allowed ◦ $2700 + $4500 = $7200  Collect $2500.00 Deductible  Plan pays 100% once deductible is met AMOUNT TO COLLECT

13.  Radiology and lab fee schedule  Surgery ASC groupers

14.  Female Patient  Yearly physical ◦ Mammogram—Digital Screening G0202 ◦ Computer Add on77051 ◦ dexa scan77080 ◦ CBC85027 ◦ lipid panel80061 ◦ TSH84443 ◦ A1C83036

15.  $1000.00 deductible/$500.00 met, 90/10 coins, max out of pocket $5000.00/$500.00 met  How much do we collect?

16. Amount AllowedAmount to Collect  G0202$170.66  77051$14.93  77080$152.39  85027$18.08  80061$37.42  84443$46.92  83036$27.11  Total for these procedures $467.21  $200.00 deductible remaining  $100.00 copay  Coinsurance Calculation  20% X $467.21 = $93.44  Collect:  $200.00 deductible, $100.00 copay, and $93.44, for total $393.44

17.  $500.00 deductible/$300.00 met, 80/20 coins, $100.00 outpatient copay, max out of pocket $1000.00/$300.00 met  How much do we collect?

18. Amount AllowedAmount to Collect  G0202$170.66  77051$14.93  77080$152.39  85027$18.08  80061$37.42  84443$46.92  83036$27.11  Total for these procedures $467.21  $200.00 deductible remaining  $100.00 copay  Coinsurance Calculation  20% X $467.21 = $93.44  Collect:  $200.00 deductible, $100.00 copay, and $93.44, for total $393.44

19.  $1000.00 deductible met, 60/40 coins, maximum out of pocket $5000.00/$4800.00 met  How much do we collect?

20.  G0202$151.16  77051$13.22  77080$134.97  85027$15.30  80061$31.66  84443$39.70  83036$22.94  Total for these procedures $408.95  Coinsurance Calculation  40% X $408.95 = $163.58

21.  Multiple Surgery Rule—100/50  Procedures 29286, 29284, 29822

22.  $2500.00 deductible/$1400.00 met, $250.00 Surgical Copay, 70/30 coinsurance, maximum out of pocket $5000.00/1400.00 met  How much do we collect?

23.  29826ungrouped procedure ◦ Unpaid  29824ASC grouper 5 (100%) ◦ $900  29822ASC grouper 3 (50%) ◦ $650.00 ◦ $650.00 x.5 = $325.00  Amount allowed ◦ $900.00 + 325.00 = $1225  Remaining Deductible $1100.00  Copay = $250.00  Collect $1225

24.  $3000.00 deductible met, 80/20 coins, maximum out of pocket $10,000/$8500.00 met

25.  29826ungrouped procedure ◦ unpaid  29824ASC grouper 5 (50%) ◦ $650.00 ◦ 0.5 x $650 = $325.00  29822ASC grouper 3 (100%) ◦ $800.00  Amount allowed ◦ $800.00 + 325.00 = $1125.00  Co-Insurance ◦ $1125.00 X.20 = $225.00  Collect $225.00

26.  $1000.00 deductible/$700.00 met, 90/10 coins, maximum out of pocket $1500/$700.00 met

27.  29826ungrouped procedure ◦ unpaid  29824ASC grouper 5 (100%) ◦ $1050.00  29822ASC grouper 3 ◦ $850.00 ◦ 0.5 X $850.00 = $425.00  Amount allowed ◦ $425.00 + 1050.00 = $1475.00  Co-Insurance ◦ 10% X $1475.00 = $147.50  $300.00 Remaining Deductible  $300.00 + 147.50 = $447.50  Collect $447.50

28.  Contracts can be complex  Different fee schedules for different procedures  Need to be familiar with the various provisions

29. Linda Fausett lcbraswell@yahoo.com