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Non-Participating Physician
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Payment

1. To start with, it should be explained that physicians are categorized as Medicare participating and non-participating doctors or physicians. A participating physician is a doctor who agrees to give necessary assistance and bill the patient for the health care services 20% only. Since October 1984, Medicare has introduced this program, under which participating doctors agree to meet all Medicare claims. This program consists of two segments of payment (Medicare payment and patients payment).The patients payment is usually 20% of the charge. Under the Medicare Advantage (MA) program, the patients can obtain their benefits. There is a slight difference in calculation of the exact amount of out of pocket costs that Mr. Roberts has to pay. The thing is that in case of being just an elderly Medicare beneficiary, he has to pay approximately 20% of the total sum. In case of being a low-income beneficiary, the sum changes. In case of Dr. Robinson, the situation is the following: the work of Dr. Robinson is paid by both Medicare and Mr. Roberts. The total sum is calculated through the formula:

Payment = (Work RUV*Work GPCI + PE RUV* PE GPCI + MP RUV * MP GPCI) * CF

Payment = (27,45 *29,98 +43,05*75,04+ 10,32*5,6) *64,43 = (822,951 +3230,472 +57,792) * 64,43=4111,215*64,43= $264885,58254

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The Medicare is obliged to pay 80% and it is $211908,466032, and Mr. Roberts is obliged to pay 20% of the sum, and it is $52977,116508.

2. The non-participating physician can accept assignment on a case-by-case basis. Although this arrangement initially might seem to be beneficial, there are several major disadvantages. First, the final non-participating physicians salary is actually lower. The limited charge is equal to 95% of the approved fee schedule. This difference may be important if the physician can recover any of the difference with other payments. However, Medicare has limited the amount of money, which the physician can get for his or her job. Medicare sets a maximum fee for a non-participating physician who elects the assignment in the sum that is equal to 95% of the approved fee schedule for a participating system. Returning to the case, if Dr. Robinson is a non-participating physician, but he continues treating Mr. Roberts, the Medicare will reimburse only 95% of the amount given to participating physicians. Again, 80% comes from the contractor and the patient pays 20%.

In this case, the sum will be the following: 100% is $264885,58254, then 95% will be $251641,303413. This is the total payment, which Dr. Robinson will receive. 80% of this sum will be paid by Medicare, it will be $ 201313,0427304. Mr. Roberts will be obliged to pay 20% of the sum, and it will be $ 50328,2606826. The calculations confirm the fact that if Dr. Robinson turns out to be the non-participating physician, it will be more financially beneficial for Mr. Roberts, as the sum of out-of pocket costs will be a bit lower.

3. If the non-participating physician decides not to elect the assignment on a claim, he or she should hold to the limiting charge set by the profile data. The physician should collect the fees for services at the time they are rendered. Although the non-participating physician has to book the insurance, the physician is not required to discuss the major difference between the sum that is allowed and the sum that is billed, as there exists an exact limit. The charge may be collected from the patient after the treatment has been provided and not when the medical service has been initially ordered. A claim is submitted to Medicare and the insurance check will be sent directly to the patient. In such situations, Medicare will still pay 80% of the allowable fee (one should take into account the fact that the total sum is 95% of the amount paid to the participating physician). However, the beneficiary is responsible for the balance in full, not just 20% of the allowable charges. It means that the patient will have to pay the limiting charge as well, and it means that he or she should pay extra 15%. In this case, Medicare covers 80% and the patient pays 35%. Thus, Medicare pays zero to Dr. Robinson. This happens due to the fact that it provides the patient with the necessary sum of money, and it is the responsibility of Mr. Roberts to pay Dr. Robinson the whole sum. The calculations are the following: the total sum which is paid to Dr. Robinson is 95% of the participating physicians fee + balance bill paid by the patient. It is 251641,303413 + 15% =251641, 303413 + 37746,19551195 = $289387,49892495. In this case, Medicare pays the same sum as in case of non-participating physician, who accepts the assignment (it is $201313,0427304), but it sends it directly to its beneficiary. Mr. Roberts is obliged to pay the rest of the sum, and it is $88074,2606286.

In general, it should be stated that it is not financially beneficial for Mr. Roberts to be treated by the non-participating physician who does not accept the assignment, as the patient has to pay an extra charge for the equal amount of services. For Dr. Robinson, the situation is different, as treating the patients in the status of non-participating physician who rejects the assignment is economically efficient, as the fee is higher.

- http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedcrephysFeeSchedfctsht.pdf
- http://67.59.137.244/documents/MedPAC_Payment_Basics_13_Physician.pdf
- http://www.nejm.org/doi/full/10.1056/NEJMp0808003