Health Care Case Study Sample Paper on Paying For Physician Services

Paying for Physician Services

The Medicare health insurance program covers for individuals aged 65 years and overand to individuals below 65 years with permanent disabilities given they are eligiblefor aRailroad Retirement Disability Benefits or Social Security Disability Insurance. Individuals with special health complications can also receive Medical insurance coverage (Cimasi, 2014).

The Medicare reimbursement is greater for services furnished by participating physicians than that of non-participating physicians. If Dr. Robinson is a participating physician, the Medical health insurance program covers Mr. Roberts’ total cost by 80%. That means that Mr. Roberts handles a 20% out-of-pocket of the total cost. The advantages of Dr. Robinson are reliability in receiving payments directly from the Medicare rather than from the customers. Participating physicians cannot charge more than 100% of the allowed amount. Hence, it is cheaper for patients to attend offices with participating physicians than those of non-participating physicians. Participating physicians seem to earn higher than non-participating physicians do because the patients choose their offices.

The Medicare reimbursement for non-participating physicians is much lower than that of participating physicians who elect assignments. In this case, Dr. Robinson is a non-participating physician who elects assignment; hence, the Medicare-allowed amount is 95% of the quantityof the participating physicians. That means that the Medicare will pay 80% of the 95% of the total amount. If a service is $100, the Medicare will pay $80 for participating physicians and $76 (80% of $95) to the non-participating physicians who elect assignments. Mr. Roberts will handle 24% out-of-pocket payment that will be $24 (Selker et. all, 2014). Non-participating physicians have the advantage of charging more but up to 115% as opposed to participating physicians. Therefore, they can charge 115%, and the Medicare pays 95% of that amount that is 107.25%.

In the case where Dr. Robinson is a Medicare non-participating physicianand does not elect services, and then the Medicare service will not cover his expenses. This means that Mr. Robertson will handle 100% of the charges by Dr. Robinson by the Medicare will reimburse Mr. Robertson. In this case, the physicians fall subject to a limit of their charges on the patient to not more than 115% of the Medicare allowed amount of payment (Edmunds et. all, 2012). Non-participating physicians who do not take claim on assignment look directly for payment from the patient. In this case, the Medicare reimburses the patient but never pays anything to the physician. A physician is legally required to submit the form of claim to Medicare on behalf of the patient even if the physician does not take a claim on assignment.

The participating physician deals with the Medicare, receive only 80% of the total amount, and cannot charge up to 115% of the total quantity while the patient pays the remainder. In non-participating physicians who elect assignment, Medicare pays 80% on 95% of the allowed amount whether it is 100% or 115%. The patient still covers the remainder. In non-participating physicians who do not elect assignment, the Medicare pays 100% of their requested amount but reimburses the patient or the physician bills a claim form to the Medicare program. Participating physicians earn less per service but get more at the end compared to participating without electing or non-participating without elect.


Cimasi, R. J. (2014). ‘The four pillars of healthcare value.’ In Selker, H. P. & Wasser, J. S. (2014). The Affordable Care Act as a National Experiment: Health Policy Innovations and Lessons. New York: Springer Science+Business Media.

Institute of Medicine (U.S.), Edmunds, M., & Sloan, F. A. (2012). Geographic adjustment in Medicare payment: Phase I. Washington, D.C: National Academies Press.