medicare casestudy revised

Case Study: Medicare
Name
Institutional Affiliation
Case Study
A non-participating physician provides services to a Medicare patient who has total charges of $100 (before Medicare’s limiting charge is applied). The physician does not accept assignment, charges the maximum allowable, and submits the claim to Medicare. Assume Medicare’s approved schedule for these services is $80.
What is the maximum amount the physician is allowed to charge the patient?
Response
The physician is allowed a maximum charge towards a patient for an unaccepted assignment at 115% of 95% of the Medicare-approved schedule (Cleverly and Cleverly, 2017). In the case provided above, the physician is thus expected to charge a maximum of the following as indicated by the calculations shown:
= 1.15*0.95*$80
=$87.40
What is the Medicare portion of the physician payment (which Medicare sends to the patient)?
Response
Medicare’s portion is 80% of the 95% of the approved schedule (Connor, 2014). Medicare’s portion of the payment accorded the physician in the case provided can only calculated as follows:
= 0.80*0.95*$80
=$60.80
What is the patient’s portion of the payment to the physician (net of the reimbursement from Medicare in the previous question)?
Response
Cleverly & Cleverly (2017) provide that a patient’s portion should be 20% of the 95% in the approved schedule. In this regard, the patient’s portion of the payment to the physician can be calculated as follows:
=0.2*0.95*$80
=$ 15.20
the physician can collect additional fee above the fee schedule of $87.

40-$60.80-$15.20 from the patient
=$11.40; and so, the total amount paid by the patient will become = =15.20+11.40
=$26.60
but, if the patient’s portion, after deducting the $60.80 in (2) above, the reimbursement received from Medicare, the portion thus comes to $15.20
Would the physician have been better off by accepting assignment on this case? Why or why not?
Response
No, the physician would not have been better off if he had accepted the case on this assignment. The case would worsen off his position because he would have received a maximum of (0.95*$80 = $76) $76 as only 95% of the approved schedule would have been received, but by not accepting assignment, he received $87.40.
How do a high percentage of Medicaid (not Medicare) patients influence a hospital’s prices?
Response
Medicaid’s patient treatment does not fit into the community service definition. As in most cases, Medicaid is not the distinguishing factor for not for profit health organizations. Medicaid’s unreimbursed costs arise majorly from operational inefficiency and not because underpayment. Hence, it cannot be included under community benefit (Cunningham et al., 2016). Apart from that, the lack of intent to serve the elderly and benefit the community by subsidized programs is another factor.
References
Cleverly, W. & Cleverly, J. (2017). Essentials of healthcare finance. Retrieved from https://bookshelf.vitalsource.com/#/books/9781284142808
Connor, E. (2014). Healthcare Finance and Financial Management: Essentials for Advanced Practice Nurses and Interdisciplinary Care Teams. Journal of the medical library association, Vol. 103(2): pp. 1-89
Cunningham, P., Rudowitz, R., Young, K., Garfield, R., and Foutz, J. (2016). Understanding Medicaid Hospital Payments and the Impact of Recent Policy Changes. Retrieved from https://www.kff.org/report-section/understanding-medicaid-hospital-payments-and-the-impact-of-recent-policy-changes-issue-brief/