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% co-insurance 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 co-insurance amount of $60 ($300 x 20%) and Carrier One will pay 100% of $240.

b.Since patient was billed $460 (amount of deductible plus co-insurance), 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 co-insurance 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 co-insurance + $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 co-insurance 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 co-insurance + $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 co-pay, 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 co-pay so the amount applied to Carrier Two is $140 (($500-$200 deductible - $100 co-pay) x 70%). Patient will pay $360 (remaining $200 deductible amount + $100 co-pay + 30% of $200).

Thank you,

Jerry