Using this fee schedule for three different payers for orthopedic procedures, complete the questions that follow.
1. A patient with BCBS PPO coverage had surgical knee arthroscopy with medial and lateral meniscectomy. The plan has an 80-20 coinsurance, with no copayment for surgical procedures. The annual deductible is met. What will the plan pay, and what amount does the patient owe?
2. A United patient has a high-deductible plan with a $1,200 deductible for this year that has not been met and 75-25 coinsurance. He has surgical knee arthroscopy with debridement. What will the plan pay, and what amount does the patient owe?
3. Another payer offers the practice a contract based on 115 percent of the Medicare Fee Schedule. What amounts are offered for the codes above?
1. Plan pays $933.78; patient owes $233.45
2. Plan pays $30.48; the patient owes $1210.16
3.
Code | Description | New Plan |
29871 | Knee arthroscopy, surgical | $557.82 |
29876 | Major synovectomy | $671.84 |
29877 | debridement | $632.02 |
29880 | w/meniscectomy, medial + lateral | $714.39 |
29881 | w/meniscectomy, medial OR lateral | $661.30 |
As with a Medicare RA, when a commercial RA is received, before posting payments and preparing secondary claims that may be required you must carefully review it. When analyzing an RA from a commercial carrier, you must be familiar with the guidelines of that carrier’s particular plan. The type of services covered and the percentage of the coverage will vary, depending on whether the plan is a fee-for-service plan, a managed care plan, a consumer-driven health plan, or some other...
A. What is the patient coinsurance percentage required under plan R-1?B. What is the patient coinsurance percentage required under plan PPO-3?C. What is Gloria Ramirez’s balance due for the two dates of service listed?
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What is the professional code and the cpt ICD-10-cm code for this case? Office consultation CC: Hip pain. Four months status post right knee arthroscopy for medial meniscectomy and debridement of ACL tear. S: The patient has become symptom-free with regard to the knee I repaired, except for a feeling that his knee might want to give way when he goes up and down stairs. He has had no locking, catching, buckling or giving way. There is no swelling and...
1. The patient's health insurance plan has a $750 deductible for hospital visits, and then it covers 100 percent of hospital visit charges. The patient's first hospital visit this year had charges of $612. The patient was subsequently admitted to the hospital a second time this year, and the charges totaled $358. How much will the patient be billed for each visit? How much will the health insurance plan reimburse for each visit?2 A patient insured under an indemnity plan...
As with a Medicare RA, when a commercial RA is received, before posting payments and preparing secondary claims that may be required you must carefully review it. When analyzing an RA from a commercial carrier, you must be familiar with the guidelines of that carrier’s particular plan. The type of services covered and the percentage of the coverage will vary, depending on whether the plan is a fee-for-service plan, a managed care plan, a consumer-driven health plan, or some other...
When a practice receives an RA from a carrier, the payment received for each procedure is posted to each patient’s account. If any patients on the RA have secondary coverage, secondary claims are then prepared unless they have automatically crossed from the primary to the secondary payer. Before doing so, however, the practice analyzes the RA to make sure the payments received are in keeping with what is expected given the office’s fee schedule, the patient’s insurance plan, and any...