Ch 16 Case Studies #10

Commercial RA/EOB Analysis

1. Anthem BCBS

2. $200; $50; 80 percent

3. $76 ($50 to fulfill her 2016 deductible plus $26 patient liability)

4. The allowed amount for the procedure is $180.

The carrier will pay for 80 percent of covered services once the deductible is met. In this case, $50 is owed toward the deductible. Therefore, the amount due for the service is reduced to $130 ($180 -$50 deductible). Anthem BCBS then pays 80 percent of $130 to the provider, or $104.

5. 80 percent; yes

6.

$15; 20 percent

7. Yes, a secondary claim should be sent to the secondary payer so that the payer has a record of benefits received or denied from the primary payer as well as how much Jean Ruff has paid toward her deductible for the year.

8. Giroux: $180; $20.80 (80% of $26.00, assuming that her secondary plan covers the routine annual physical)

Ruff: $75; $0 (100% of $15 = $15, minus the $15 copay)

Preparing Secondary Claims

See the answer keys for Claim Case Studies 16.4 A-B below, for Anthem BCBS patients Giroux and Ruff.

ANSWERS TO CALCULATING PATIENTS’ BALANCES

Claim Case Study 16.4 A

Claim Case Study 16.4 B