Wiki CALCULATING MEDICARE PAYMENT

[jenjas0206]

Hello Everyone!
I am trying to determine if Medicare paid their 80%, but I am having trouble calculating the amounts. I was looking online for the exact formula to follow, but I am getting a lot of info and I was not sure what to use. I know that for a participating provider Medicare will pay 80%, but is that of the total submitted charges or what they allowed? I will need to also calculate the 20% coins for the patient's secondary. I do have the remit, but I am trying to make sure that what was paid was correct. Any advice will be appreciated. I have uploaded a copy of the remit.
Thanks!
Jen

 

[SharonCollachi]

It's never 80% of billed amount; it's 80% of allowed amount, for outpatient services. Is this outpatient?

Billed = $50,931.05
Adjust = 47,650.37
Total allowed=3,280.68
80% of allowed = $2624.54 (your eob shows $2618.07, and the difference looks like another adjustment for ESRD)
Total allowed minus 80% = $656.14 (your EOB shows $656.11) for copay/coinsurance/patient responsibility

The EOB shows they have already forwarded it to the patient's secondary, so you don't need to do that.

 

[jenjas0206]

Thank you!! I was not calculating the ESRD adjustments. The COINS on the EOB does not match what is on the Medicare EOB by a few cents, is that something that would need to be readjusted?
Again thank you so much, I was driving myself nuts trying to figure it out
Jen

 

[jenjas0206]

It's never 80% of billed amount; it's 80% of allowed amount, for outpatient services. Is this outpatient?

Billed = $50,931.05
Adjust = 47,650.37
Total allowed=3,280.68
80% of allowed = $2624.54 (your eob shows $2618.07, and the difference looks like another adjustment for ESRD)
Total allowed minus 80% = $656.14 (your EOB shows $656.11) for copay/coinsurance/patient responsibility

The EOB shows they have already forwarded it to the patient's secondary, so you don't need to do that.

Sorry, this is for out patient dialysis services