instructor: laurie amdur, cpar, cfc, pas. room types—medical, surgical, icu, & intermediate...
TRANSCRIPT
Financial Counseling: Insurance Requirements
Lesson 2: Interpreting Your Insurance Contracts to
Calculate Patient Responsibility
Instructor: Laurie Amdur, CPAR, CFC, PAS
TheMedical Center
Testing Your Calculation Skills
Room types—Medical, Surgical, ICU, & Intermediate ICU
Authorized vs. Charged Payment for outside services—radiologists, physicians, pathologists, anesthesiologists, etc
Inpatients
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?
Blue Cross
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
Total Amount Allowed
Deductible = $5000 Coins calculation
◦20% X $9000.00 = $1800.00
Total to collect ◦$5000.00 + $1800.00 = $6800.00
Amount to Collect
$3000.00 deductible, $100.00/day Inpatient copay, 70/30 coinsurance, max out of pocket $5000.00
How much do we collect?
Cigna
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
Amount Allowed
$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)
Amount to Collect
$2500.00 deductible, then 100%
How much do we collect?
United Healthcare
Calculations
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
Radiology and lab fee scheduleSurgery ASC groupers
Outpatients
Female Patient Yearly physical
◦Mammogram—Digital Screening G0202◦Computer Add on 77051◦dexa scan 77080◦CBC 85027◦lipid panel 80061◦TSH 84443◦A1C 83036
Lab and Radiology
$1000.00 deductible/$500.00 met, 90/10 coins, max out of pocket $5000.00/$500.00 met
How much do we collect?
Blue Cross
Blue Cross
Amount Allowed Amount 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
$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?
Cigna
Cigna
Amount Allowed Amount 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
$1000.00 deductible met, 60/40 coins, maximum out of pocket $5000.00/$4800.00 met
How much do we collect?
United Healthcare
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
United Healthcare Calculations
Multiple Surgery Rule—100/50Procedures 29286, 29284, 29822
Surgery
$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?
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
Blue Cross
$3000.00 deductible met, 80/20 coins, maximum out of pocket $10,000/$8500.00 met
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
Cigna
$1000.00 deductible/$700.00 met, 90/10 coins, maximum out of pocket $1500/$700.00 met
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
United Healthcare
Contracts can be complex Different fee schedules for different procedures
Need to be familiar with the various provisions
Summary
