Review the lecture information prior to completing this task. This scenario is for a non-physician provider, such as an N.P. or P.A., who contracts with Medicare. More information is available to you in Chapter 9 of your text.
Analyze a scenario to determine monetary responsibility for a visit.
Fill in the blanks in the following payment situations:
Scenario 1
Calculate the following amounts for an NP who bills Medicare as an incident to a supervising physician (billed under the physician’s NPI).
Submitted charge $75
Medicare allowed amount (MPFS) $60
Nurse practitioner allowed amount (100% of MPFS) $
Medicare payment (80 percent of the allowed amount) $
Coinsurance amount (20% allowed amount) $
Provider write-off $
Scenario 2
Calculate the following amounts for an NP who bills Medicare under their own NPI.
Submitted charge $75
Medicare allowed amount (MPFS) $60
Nurse practitioner allowed amount $
(80% of office charge or 85% of MPFS whichever is lower)
Medicare payment (80% of the allowed amount) $
Coinsurance amount $
Provider write-off $
Scenario 2: Billing Under the NP's Own NPI (Direct Billing)
When an NP/PA bills directly under their own NPI, Medicare reduces the allowed amount to 85% of the Medicare Physician Fee Schedule (MPFS) amount.
| Item | Calculation | Amount |
| Submitted charge | Given | $75 |
| Medicare allowed amount (MPFS) | Given | $60 |
| Nurse practitioner allowed amount | (85% of MPFS) | 0.85×$60=$51 |
| Medicare payment | (80% of the NP's allowed amount) | 0.80×$51=$40.80 |
| Coinsurance amount | (20% of the NP's allowed amount) | 0.20×$51=$10.20 |
| Provider write-off | (Submitted Charge - NP Allowed Amount) | $75−$51=$24 |
Export to SheetsSummary of Responsibility (Scenario 2):
Medicare Pays: $40.80
Patient Owes (Coinsurance): $10.20
Provider Must Write Off: $24
Total Payment to Provider: $51 (NP Allowed Amount)
Sample Answer
Scenario 1: Billing "Incident To" a Supervising Physician
When an NP/PA bills "incident to" a physician, Medicare treats the service as if the physician personally provided it.
| Item | Calculation | Amount |
| Submitted charge | Given | $75 |
| Medicare allowed amount (MPFS) | Given | $60 |
| Nurse practitioner allowed amount | (100% of MPFS) | $60 |
| Medicare payment | (80% of the allowed amount) | 0.80×$60=$48 |
| Coinsurance amount | (20% allowed amount) | 0.20×$60=$12 |
| Provider write-off | (Submitted Charge - Allowed Amount) | $75−$60=$15 |
Export to SheetsSummary of Responsibility (Scenario 1):
Medicare Pays: $48
Patient Owes (Coinsurance): $12
Provider Must Write Off: $15
Total Payment to Provider: $60 (Allowed Amount)