Step-by-step explanation:
To fill in the calculation table, we need to calculate the missing values based on the given information. Let's solve this step by step.
Given:
- Submitted charge (based on provider's regular fee): $650
- Medicare-participating physician fee schedule allowed amount: $450
Step 1: Calculate the Medicare Non-participating physician allowed amount.
Medicare Non-participating physician allowed amount = MPFS allowed amount × (1 - 0.05)
Medicare Non-participating physician allowed amount = $450 × (1 - 0.05) = $450 × 0.95 = $427.50
Step 2: Calculate the Medicare payment.
Medicare payment = Medicare Non-participating physician allowed amount × 0.80
Medicare payment = $427.50 × 0.80 = $342
Step 3: Calculate the limiting charge to the patient.
Limiting charge to patient = [MPFS - (MPFS × 0.05)] × 1.15
Limiting charge to patient = [$450 - ($450 × 0.05)] × 1.15 = $427.50 × 1.15 = $491.63
Step 4: Calculate the patient payment.
Patient payment = Limiting charge to patient - Medicare payment
Patient payment = $491.63 - $342 = $149.63
Step 5: Calculate the provider write-off.
Provider write-off = Submitted charge - Limiting charge to patient
Provider write-off = $650 - $491.63 = $158.37
[tex]\begin{array}{ | c | c | }\hline \text{Item} & \text{Calculated Amount} \\ \hline \text{Submitted charge (based on provider’s regular fee)} & \$650 \\ \hline \text{Medicare-participating physician fee schedule allowed amount} & \$450 \\ \hline \text{Medicare Non-participating physician allowed amount} & \$427.50 \\ \hline \text{Medicare payment} & \$342 \\ \hline \text{Limiting charge to patient} & \$491.625 \\ \hline \text{Patient payment} & \$149.625 \\ \hline \text{Provider write-off} & \$158.375 \\ \hline \end{array}[/tex]
