You have been hired as the billing manager for Nash Medical Center and Clinics. One of your responsibilities is to calculate what the patient owes and what the insurance company owes, so that you can determine what revenue to expect for these services. You have the charge and the usual, customary, and reasonable (UCR) amount. The reimbursement will be calculated on the 80/20 distribution. The deductibles for each of these patients have been met. Under this insurance plan, $20.00 copays are due for primary care physician office visits and $40.00 copays for specialists. There is no copay for other services.

The Medical Center also recently negotiated with a group of employers to treat their patients based on a capitated amount of $750 per person per month. This group of employers has combined 6,525 employees. You predict that your cost will be $610 per month per person.

The budgeted revenue was initially $1,575,000.

You were provided with the following report.

Service

Charge

UCR

Patient's Copay

Patient's Coinsurance

Insurance Pays

Patient Owe

Internal medicine

$120.00

$120.00

Physical therapy

$150.00

$97.00

X-ray

$115.00

$73.00

MRI

$1,845.00

$147.00

Specialty visit

$165.00

$90.00

Specialty visit

$75.00

$70.00

Lab test

$32.00

$19.00

Lab test

$45.00

$29.00

Mammogram

$151.00

$95.00

Using the reimbursement information, calculate:

• Coinsurance
• Copay amount, if any
• Amount insurance will pay
• How much the patient owes

Based on the negotiated capitation amount, predict:

• Total amount of revenue per month
• Total amount of revenue per year
• Total profit expected per month
• Total profit expected per year

An executive summary is a document or proposal that provides a brief overview or summary. In this case, it is used to summarize the findings of your report.

executive summary:

• Summarize your reimbursement data.
• Determine what revenue to expect for each of the services the services.
• Summarize your prediction and forecasting data.
• Compare to the budgeted revenue.
• Explain potential reasons for budget variances.

Submit your executive summary and calculations.

Grading Criteria

Points

Provide reimbursement calculations.

15 points

Provide negotiated capitation calculations.

10 points

Summarize reimbursement data.

15 points

Determine what revenue to expect for each of the services the services.

10 points

Summarize prediction and forecasting data.

20 points

Compare to the budgeted revenue.

15 points

Explain potential reasons for budget variances.

15 points

Total Points

100 points

AHIMA 2014 Entry-Level Competency

Domain IV. Revenue Cycle

Subdomain VI. A. Revenue Cycle and Reimbursement

Entry-Level Competencies Student Learning Outcomes

Subdomain IV. A. Revenue Cycle and Reimbursement

3. Apply principles of healthcare finance for revenue management

Start Date

Dec 14, 2020 12:00 AM

Due Date

Dec 21, 2020 12:00 AM

Attachments

Domain IV. Subdomain IV.A.3._HIMA240 Assignment...(114.09 KB)Download All Files

Using the reimbursement information, calculate:

• Coinsurance
• Copay amount, if any
• Amount insurance will pay
• How much the patient owes

Based on the negotiated capitation amount, predict:

• Total amount of revenue per month
• Total amount of revenue per year
• Total profit expected per month
• Total profit expected per year

An executive summary is a document or proposal that provides a brief overview or summary. In this case, it is used to summarize the findings of your report.

executive summary:

• Summarize your reimbursement data.
• Determine what revenue to expect for each of the services the services.
• Summarize your prediction and forecasting data.
• Compare to the budgeted revenue.
• Explain potential reasons for budget variances.