Southern Sennet Insurance Company offers a PPO health plan called PPO Windward. Southern Sennet maintains provider...

 

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Southern Sennet Insurance Company offers a PPO health plan called "PPO Windward". Southern Sennet maintains provider contracts with two outpatient surgery centers, Marquesa SurgiCenter, LLC, and Tortuga Surgery, Inc. Southern Sennet Insurance Company's contract with Marquesa SurgiCenter specifies that arthroscopy procedures for Southern Sennet enrollees will be reimbursed at 60 percent of Marquesa's charges. Southern Sennet Insurance Company's contract with Tortuga Surgery specifies that arthroscopy procedures for Southern Sennet enrollees will be reimbursed at $1,500. Patient G, a Southern Sennet subscriber, underwent an arthroscopy at Marquesa SurgiCenter on Tuesday, with total charges of $2,600. How much is owed as reimbursement to Marquesa for the procedure? Would Southern Sennet Insurance Company have been better off financially if Patient G had received the procedure at Tortuga Surgery? At what level of charges by Marquesa SurgiCenter would the expense to Southern Sennet Insurance Company have been the same as having an arthroscopy at Tortuga Surgery? (For purposes of this exercise, assume there is no patient deductible or copayments, i.e., the insurance company pays the full amount owed under the contract) Southern Sennet Insurance Company offers a PPO health plan called "PPO Windward". Southern Sennet maintains provider contracts with two outpatient surgery centers, Marquesa SurgiCenter, LLC, and Tortuga Surgery, Inc. Southern Sennet Insurance Company's contract with Marquesa SurgiCenter specifies that arthroscopy procedures for Southern Sennet enrollees will be reimbursed at 60 percent of Marquesa's charges. Southern Sennet Insurance Company's contract with Tortuga Surgery specifies that arthroscopy procedures for Southern Sennet enrollees will be reimbursed at $1,500. Patient G, a Southern Sennet subscriber, underwent an arthroscopy at Marquesa SurgiCenter on Tuesday, with total charges of $2,600. How much is owed as reimbursement to Marquesa for the procedure? Would Southern Sennet Insurance Company have been better off financially if Patient G had received the procedure at Tortuga Surgery? At what level of charges by Marquesa SurgiCenter would the expense to Southern Sennet Insurance Company have been the same as having an arthroscopy at Tortuga Surgery? (For purposes of this exercise, assume there is no patient deductible or copayments, i.e., the insurance company pays the full amount owed under the contract)

Answer rating: 100% (QA)

Step 13 SOLUTION Considering that the Southern Sennet Insurance Co... View the full answer