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COMMERCIAL INSURANCE REIMBURSEMENT
Commercial Insurance Reimbursement and Capitation
Name
Institution
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COMMERCIAL INSURANCE REIMBURSEMENT
Instructions for this assignment:
Part I: Determine the patient’s responsibility by completing the chart.
Using the reimbursement information, calculate:
Based on the information provided, 20% of the costs are covered by the patient while the
insurance company covers 80%. For the purpose of the calculation, we will use 80% of the
UCR amount.
a) 120 x .80 = 96; 120 x .20 = 24 + 20 = 44
b) 97 x .80 = 77.6;97 x .20 = 19.4
c) 73 x .80 = 58.4; 73 x .20 = 14.6
d) 147 x .80 = 117.6; 147 x .20 = 29.4
e) 90 x .80 = 72; 90 x .20 = 18 + 40 = 58
f) 70 x .80 = 56;70 x .20 = 14 + 40 = 54
g) 19 x .80 = 15.2;19 x .20 = 3.8
h) 29 x .80 = 23.2;29 x .20 = 5.8
i) 95 x .80 = 76; 95 x .20 = 19
Part II: Based on the negotiated capitation (pm) amount, predict:
Expected revenue= Revenue per person*total number of employees
750 x 6525 = 4,893,750
Annual revenue= 4,893,750*12= 58,725,000
Expected profit=Expected revenue-expected costs
=4,893,750- (610*6525)
=913,500
Annual profit=913,500*12=10,962,000
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COMMERCIAL INSURANCE REIMBURSEMENT

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Summarize your prediction and forecasting data.
Based on the data, the organization is expected to make a profit of 10,962,000 annually. This
profit shows that the organization will be able to meet its obligations to different stakeholders
and still generate enough profit to sustain its daily activities.
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