Instructor: Laurie Amdur, CPAR, CFC, PAS

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

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

 Calculation for Medical ◦ $ X 3 = $  Calculation for ICU ◦ $ X 3 = $  Total amount Allowed (ICU + Medical) ◦ $ = $

 Deductible = $5000  Coins calculation ◦ 20% X $ = $  Total to collect ◦ $ $ = $

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

 Calculation for Medical ◦ $1200/day x 3 days = $3600  Calculation for ICU ◦ $2000/day x 3 days = $6000  Total Allowed ◦ $ = $

 $ deductible  $ copay per day ◦ 6 X $ = $  Coinsurance Calculation ◦ 30% X $ = $  Maximum OOP is $  Collect $ ($ $600.00)

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

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

 Radiology and lab fee schedule  Surgery ASC groupers

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

 $ deductible/$ met, 90/10 coins, max out of pocket $ /$ met  How much do we collect?

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

 $ deductible/$ met, 80/20 coins, $ outpatient copay, max out of pocket $ /$ met  How much do we collect?

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

 $ deductible met, 60/40 coins, maximum out of pocket $ /$ met  How much do we collect?

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

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

 $ deductible/$ met, $ Surgical Copay, 70/30 coinsurance, maximum out of pocket $ / met  How much do we collect?

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

 $ deductible met, 80/20 coins, maximum out of pocket $10,000/$ met

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

 $ deductible/$ met, 90/10 coins, maximum out of pocket $1500/$ met

 29826ungrouped procedure ◦ unpaid  29824ASC grouper 5 (100%) ◦ $  29822ASC grouper 3 ◦ $ ◦ 0.5 X $ = $  Amount allowed ◦ $ = $  Co-Insurance ◦ 10% X $ = $  $ Remaining Deductible  $ = $  Collect $447.50

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

Linda Fausett