In the past, for Medicare Outpatient Estimates, PPE would determine the Medicare Coinsurance by taking 20% of the APC Contracted Rate for the procedures on the estimate. For each estimate, the patient would then owe the 20% coinsurance and any deductible remaining. This 20% was a generality and not the exact amount that Medicare actually charged the patient. This got our estimates close, but they were not exact.
Recently, we have made an update to how PPE calculates the Medicare Coinsurance for the PPE Medicare Outpatient Estimates. Our update enables us to determine exactly what Medicare would charge a patient for coinsurance for each individual procedure. This means that the coinsurance is not necessarily 20% any longer. Medicare uses the APC Contracted Rate, the National Unadjusted Copayment and the Payment Rate to determine exactly what the coinsurance should be for a particular procedure. Typically, the coinsurance can range from 0% – 40% of the APC Contracted Rate. This means that PPE will no longer display the average 20% in the coinsurance field. PPE now uses the same calculation as Medicare, and will determine the exact coinsurance for each procedure. While this is a change from what users typically would see on the PPE screen, it will increase the accuracy of Outpatient Medicare Estimates going forward.
