How many benefit periods were used during calendar year

Reference no: EM132396388

Assignment: 1. Under the outpatient prospective payment system, Medicare decides how much a hospital or a community mental health center will be reimbursed for each service rendered. Depending on the service, the patient pays either a coinsurance amount (20%) or a fixed copayment amount, whichever is less. For each case below, determine whether the patient will pay the coinsurance or copayment amount.

a. Mr. Smith was charged $85 for a minor procedure performed in the hospital outpatient department. The fixed copayment amount for this type of procedure, adjusted for wages in the geographic area, is $15. Mr. Smith has already paid his annual Medicare Part B deductible of $100.

b. Mr. Jones and Mrs. Day live in the same area of the country. They are having the same outpatient procedure done, but at different hospitals. Mr. Jones's hospital charges $250 for the procedure, but Mrs. Day's hospital charges $150. The national median charge for this procedure is $225 (adjusted for wages in their area) with a fixed copayment of $54. Both patients have already paid their $135 yearly Medicare Part B deductible.

2. Alfred State Medical Center's charges, payments, and adjustments from third-party payers for the month of July are represented in table 7-W1.

Table 7-W1

Payer	Charges	Payments	Adjustment	Charges	Payments	Adjustments
BC/BS	$450,000	$360,000	$90,000
Commercial	$250,000	$200,000	$50,000
Medicaid*	$350,000	$75,000	$275,000
Medicare	$750,000	$495,000	$255,000
TRICARE*	$150,000	$50,000	$100,000
Totals	$1,950,000	$1,180,000	$770,000	100%	100%	100%

a. Calculate the percentage of charges, payments, and adjustments for each third-party payer and enter the percentages in the percentages columns of table 7W1.

* Managed care capitated payment for period

b. Based on the percentages calculated in the charges column, identify the payer the facility does the most business with and the payer it does the least business with.

c. Based on the percentages calculated in the payment column, identify the payers that reimburse the facility the most and the least.

d. Based on the percentages calculated in the adjustments column, identify the payers that proportionately reimburse the facility the most and the least.

3. Use table W7.2 and table W7.3 to answer the following questions.

Table W7.2. Sample RVUs for selected HCPCS Codes

HCPCS Code	Description	Work RVU	Practice Expense RVU	Malpractice Expense RVU
99203	Office Visit	1.23	0.48	0.09
99204	Office Visit	2.00	0.71	0.12
10080	I&D of pilonidal cyst, simple	1.17	1.11	0.11
45380	Colonoscopy with biopsy	4.43	1.73	0.35
52601	TURP, complete	12.35	5.1	0.87

Table W7.3. Sample GPCIs for selected U.S. Cities

City	Work GPCI	Practice Expense GPCI	Malpractice Expense GPCI
St. Louis	1.000	0.946	0.941
Dallas	1.010	1.063	1.061
Seattle	1.010	1.115	0.819
Philadelphia	1.020	1.098	1.386

a. How much can a physician in St. Louis bill Medicare for an office visit for a new patient with a detailed history and physical and low-complexity medical decision making (assuming the patient has met any deductible for the year)? Assume a conversion factor of $34.0682

b. In which city would a physician receive the highest reimbursement for a TURP?

c. In which city would a physician receive the lowest reimbursement for a colonoscopy with biopsy?

d. Calculate the expected payment for an incision and drainage of a pilonidal cyst in each of the cities listed. Conversion Factor: $34.0682

4. Jane Doe is an 83-year-old patient who only has Medicare Part A insurance. Using the following information, calculate the patient's financial responsibility for each hospitalization and answer the questions regarding her listed hospitalizations:

Table W 7.W4

DATE ADMITTED	DATE DISCHARGED	PATIENT'S FINANCIAL RESPONSIBILITY
01/01	01/13	$1,024
03/20	03/30	$1,024
07/04	11/02	$24,576 ($1,024 + 7,680 + 15,872)
12/01	12/05	$2,560

a. How many benefit periods were used during this calendar year?

b. Were any lifetime reserve days used during this period of time? If so, how many?

c. If lifetime reserve days were used, how many does the patient have left to be used at a later date?

d. How many times was the patient required to pay a hospital deductible during this time period?

5. Following the last hospital admission, Jane was transferred to a skilled nursing facility (SNF) and remained there for continued treatment for 22 days.
a. How much was Jane required to pay for her SNF care for days 1-20?

b. How much was she required to pay for the remainder of her SNF stay?

6. After Jane's discharge from the skilled facility, she received home health care as prescribed by her physician for 14 days. During this time period, she met all of Medicare's medical necessity criteria for her care. How much was Jane required to pay for her home health care?

Reference no: EM132396388

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