If the Medicare non-PAR approved payment amount is $128.00 for a proctoscopy, what is the total approved payment amount for a doctor who does not accept assignment?

To determine the total approved payment amount for a doctor who does not accept Medicare assignment, one must understand how Medicare payment is structured in such scenarios.

In instances where a provider is a non-participating (non-PAR) provider, Medicare pays 95% of the approved amount for that service. Given that the Medicare non-PAR approved payment for a proctoscopy is $128.00, the first step is to calculate 95% of this amount.

Calculating 95% of $128.00 involves multiplying $128.00 by 0.95, which yields $121.60. This is the amount that Medicare will pay to the physician. However, when a non-PAR provider performs the service, they can also bill the patient for what is referred to as the "balance billing" amount. This is typically capped by CMS at an additional 15% beyond the Medicare approved amount.

Therefore, the maximum that the physician can charge the patient is 115% of the approved Medicare payment amount. In this case, calculating 115% of $128.00 gives $147.20.

Hence, the total approved payment amount when a non-PAR provider is involved is $147.20, which confirms