Case Study: Dr. Maxwell Stark is a PAR provider with Blue Cross and Blue Shield;
ID: 2736262 • Letter: C
Question
Case Study:
Dr. Maxwell Stark is a PAR provider with Blue Cross and Blue Shield; Dr. Forrest Wilson is nonPAR with the same insurer. Both providers are specialists in gastroenterology. Both physicians charge $1000 for a colonoscopy. Blue Cross and Blue Shield allows $700 as its UCR fee for this procedure. Assuming each provider has a patient who undergoes a colonoscopy, each patient has satisfied his or her yearly deductible, and each has paid the same amount of coinsurance (20% of the "allowable" charge--$140), how much can Dr. Stark bill his colonoscopy patient? How much can Dr. Wilson bill his patient?
Explanation / Answer
Dr. Maxwell Stark is a PAR provider's Bill Amount
He bills Blue Cross and Blue Shield directly an amount called PAR fee which is the UCR fee = $ 700
PAR fee 700
Patient coinsurance 20%*700= 140 (Patient Share 20%)
Blue Cross pays 80%*700= 560 (Blue Cross and Blue Shield Share 80%)
Dr. Stark 's Bill amount= $ 700
Dr. Forrest Wilson - nonPAR Provider
Limiting Charge = 15% higher than Non-par fee ;
& non-par fee is 5% less than Par fee (700*95/100= 665)
So, 115%*(700*95%) = 764.75
Patient Share =99.75
Non par fee (Total) = 665
Patient Coinsurance 20%*665 = 133
Blue Cross pays(80%*665) =532
Total Patient share =99.75+133 = 232.75 (232.75/764.75*100 = 30.43%)
Blue Cross & Blue Shield's Share = 532 (532/764.75*100 = 69.57%)
Dr. Forrest Wilson's Bill amount -- $ 764.75
Dr. Maxwell Stark---Par Provider Blue Cross & Blue Shieldsallowed- Amount-Par fee 700 Patient Co-Insurance (20% *700) 140 Blue Cross pays 80% *700 560 Amt. to be paid by Patient 140 Amt. to be paid by Blue Cross 540 Dr. Forrest Wilson--- Non-Par Provider Non-Par Fee 5% less than par Fee 700 665 Limiting amount --115%*Non par fee 764.75 Patient share 764.75-665= 99.75 Patient Co-Insurance (20% of Non-Par Fee)=20*665 133 Blue Cross Pays (80% of Non-Par Fee)=(80%*665) 532 So, total Patient Share 99.75+133 232.75 30.43% Total Blue Cross share 532 69.57% 764.75 100.00% Dr. Maxwell Stark---Par Provider"s bill amt. 700 Dr. Forrest Wilson--- Non-Par Provider's bill amt.700*95%*1.15= 764.75 Non-par provider's fee is 5% less than par provider's fee set to a limiting charge of 15%*non-par fee