Medical Billing Forum
General Category => General Questions => Topic started by: jerrywrose on February 12, 2014, 10:28:51 AM

Was wondering if someone could review these billing problems and tell me if I did them correctly.
Calculate the amount due from the insurance carrier and the amount due from the patient for the following examples (please show your calculations):
Insurance contract – Carrier One
Pays 100% 1st procedure, 50% all others
Grouper rates:
1 300
2 500
3 600
4 700
Insurance Contract – Carrier Two
Pays 70% of billed charges
Example 1
Patient has Carrier One as their insurance, a 20% coinsurance amt, and has met $100.00 of their $500.00 deductible
The following charges were submitted:
Cpt code – 29881 – group 4, charges are 4250.00
Cpt code – 29877 – group 4, charges are 5000.00
Cpt code – 75006 – group 1, charges are 500.00
Assumptions:
1. Carrier One is primary insurance and will pay first
2. Carrier Two is secondary insurance.
Calculations
1.For CPT Code 29881
a.Contract rate is $700, patient has $400 left on deductible so this leaves $300 to be applied to Carrier One. Patient pays coinsurance amount of $60 ($300 x 20%) and Carrier One will pay 100% of $240.
b.Since patient was billed $460 (amount of deductible plus coinsurance), Carrier Two will pay $322 ($460 x 70%). This leaves $138 for the patient.
2. For CPT Code 29877
a. Patient deductible for Carrier One has been met through the previous procedure. Contract rate is $700. Patient has coinsurance amount of $140 ($700 x 20%) leaving $560. Carrier One will now pay $280 ($560 x 50%).
b. Since the patient was billed for $420 ($140 coinsurance + $280 50% amount), Carrier Two will pay $294 ($420 x 70%). This leaves $126 ($420$294) for the patient.
3. For CPT Code 75006
a. Patient deductible for Carrier One has been met through the previous procedure. Contract rate is $300. Patient has coinsurance amount of $60 ($300 x 20%) leaving $240. Carrier One will now pay $120 ($240 x 50%).
b. Since the patient was billed for $180 ($60 coinsurance + $120 50% amount), Carrier Two will pay $126 ($180 x 70%). This leaves $54 ($180$126) for the patient.
Example 2
Patient has Carrier Two as their insurance, a $100.00 copay, and has not met their $500.00 deductible
The following charges were submitted:
Cpt code – 62311 – group 1, charges are $1700.00
Cpt code – 64590 – group 2, charges are $2300.00
1. For CPT Code 62311
a. Contract rate is $300. Since the patient has not met any of their $500 deductible, they are responsible for the full amount of $300.
b. Carrier Two pays nothing
2. For CPT Code 64590
a. Contract rate is $500. Patient has $200 of deductible left plus $100 copay so the amount applied to Carrier Two is $140 (($500$200 deductible  $100 copay) x 70%). Patient will pay $360 (remaining $200 deductible amount + $100 copay + 30% of $200).
Thank you,
Jerry

Sounds like a homework assignment or an exam. Should we REALLY be doing this. Don't want to deny anyone help but...

It's not formal homework or part of an exam. I'm trying to teach myself medical billing. I bought a book on this site called "The Basics of Medical Billing" and read it. However, there weren't any practical application problems. So I did a google search and found some problems, but no answer key. I worked the problems on my own and just want to know if I did them correctly. Not tryng to get over on anyone. Just don't have a lot of of money to attend formal classes
Thanks,
Jerry

I think it's more beneficial to you to work through learning billing in a better way. I'm sorry but A "BASIC HOW TO" is not a good way to learn this business. Remember that this is the second largest government regulated industry in the world only second to banking. YOU do NOT want to learn from a book.
Not trying to be harsh but you need formal training and education.

I appreciate your input, but the email I got when I puchased the book said I could get help here. That really isn't helping me.
Was the offer of help just an empty promise so I would buy a book?
Integrity check time.
Jerry

We don't mind trying to help anyone with billing issues, whether they have purchased anything or not. Many of the forum members have never purchased anything. We also get many questions from students regarding homework, which I don't mind trying to help them but I'm not helping by just giving the answer. So you can't blame us for asking. :) Anyway, I would be more than happy to try to check your logic but there is some things that are confusing for me. It states first that Insurance carrier 1 "pays 100% 1st procedure, 50% all others" but then later it states that insurance carrier 1 has a deductible and pays 80/20. I also have to say I am not sure where the grouper rates are coming into play. What types of questions are you specifically looking for? I truly don't mind helping you understand what it is you are looking to understand. Maybe we can give a couple examples?
Michele