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Instructor: Laurie Amdur , CPAR, CFC, PAS

Financial Counseling: Insurance Requirements Lesson 2: Interpreting Your Insurance Contracts to Calculate Patient Responsibility. Instructor: Laurie Amdur , CPAR, CFC, PAS. The Medical Center. Testing Your Calculation Skills. Inpatients.

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Instructor: Laurie Amdur , CPAR, CFC, PAS

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  1. Financial Counseling: Insurance RequirementsLesson 2: Interpreting Your Insurance Contracts to Calculate Patient Responsibility Instructor: Laurie Amdur, CPAR, CFC, PAS

  2. TheMedical Center

  3. Testing Your Calculation Skills

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

  5. Blue Cross • 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. Total Amount Allowed • 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. Amount to Collect • Deductible = $5000 • Coins calculation • 20% X $9000.00 = $1800.00 • Total to collect • $5000.00 + $1800.00 = $6800.00

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

  9. Amount Allowed • 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. Amount to Collect • $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. United Healthcare • $2500.00 deductible, then 100% • How much do we collect?

  12. Calculations • 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 ALLOWED AMOUNT TO COLLECT

  13. Outpatients • Radiology and lab fee schedule • Surgery ASC groupers

  14. Lab and Radiology • Female Patient • Yearly physical • Mammogram—Digital Screening G0202 • Computer Add on 77051 • dexa scan 77080 • CBC 85027 • lipid panel 80061 • TSH 84443 • A1C 83036

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

  16. Blue Cross • 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 Amount Allowed Amount to Collect

  17. Cigna • $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. Cigna • 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 Amount Allowed Amount to Collect

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

  20. United Healthcare Calculations • 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. Surgery • Multiple Surgery Rule—100/50 • Procedures 29286, 29284, 29822

  22. Blue Cross • $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. Blue Cross • 29826 ungrouped procedure • Unpaid • 29824 ASC grouper 5 (100%) • $900 • 29822 ASC 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. Cigna • $3000.00 deductible met, 80/20 coins, maximum out of pocket $10,000/$8500.00 met

  25. Cigna • 29826 ungrouped procedure • unpaid • 29824 ASC grouper 5 (50%) • $650.00 • 0.5 x $650 = $325.00 • 29822 ASC 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. United Healthcare • $1000.00 deductible/$700.00 met, 90/10 coins, maximum out of pocket $1500/$700.00 met

  27. United Healthcare • 29826 ungrouped procedure • unpaid • 29824 ASC grouper 5 (100%) • $1050.00 • 29822 ASC 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. Summary • Contracts can be complex • Different fee schedules for different procedures • Need to be familiar with the various provisions

  29. CONTACT Linda Fausett lcbraswell@yahoo.com

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