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MEDICAL SERVICES POLICY MANUAL,SECTION O
EXAMPLE: Mr. Doe is hospitalized for 4 days; daily charges, less room charge, are $1325, $1000, $900 and $700 for days 1-4, respectively; the room charge is $250 a day. Mr. Doe has insurance which pays 80 per cent of total charge, less room charge, less any unmet deductible. The insurance also pays a $200 per diem on room charge. The insurance payment and Mr. Doe’s liability are determined as follows:
Unit Charges Unit Payments Unit Liability Days Room Other - Room Other = Room Other 7/1 $250 $1325 - $200 $1060 = $50 $265 7/2 $250 $1000 - $200 $800 = $50 $200 7/3 $250 $900 - $200 $720 = $50 $180 7/4 $250 $700 - $200 $560 = $50 $140 Unit Total 4 $1000 $3925 $800 $3140 $200 $785 (Plus any unmet Deductible) Grand Total 4 $4925 $3940 $985 (Plus any unmet Deductible)
Some private insurance (e.g., Medipak, which only covers the deductible and coinsurance charges that Medicare does not pay) provides limited coverage only. Although private insurance offers an infinite variety of coverage plans, most companies make payment using one of the methods described or a similar method. Nonmedical charges (e.g., charge for telephone, television, etc. while hospitalized) cannot be deducted from excess income even though the charges are a liability of the individual.
O-753 Nonspecific Assignable Payments MS Manual 01/01/14 When a third party resource makes or indicates that it will make a nonspecific assignable payment (method of calculating payment is not known), the payment will be applied in the following manner. Divide the nonspecific payment by total charges to determine the percent of payment. For cases in which the charges are not itemized (i.e. only a total summary of charges is available), it will be necessary to divide the charges by the dates of service to determine an average daily charge. Apply the percent of payment to each daily charge to determine the amount of charge covered by the payment. The balance of each daily charge (if any) is the liability of the individual.