Chapter 1 / Quiz 1
A physician has a contract to receive a $2,000 monthly capitation fee, based on a fee of $50 for 40 patients who are in the plan. However, since only 10 patients visited the practice in the last month, the capitation payment will be
$2,000
Calculate the amount of money a patient would owe for a covered service costing $1,200 if their indemnity policy has a coinsurance rate of 75-25, and they have already met their deductible.
$300
Calculate the amount of money the insurance company would owe on a covered service costing $850 if there is a $500 deductible (which has not yet been met) and no coinsurance.
$350
Calculate the amount of money a patient would owe for a covered service costing $1,800 if their indemnity policy has a $400 deductible (which has not been met) and their coinsurance rate is 80-20.
$680
Calculate the amount of money a patient would owe for a noncovered service costing $900 if their indemnity policy has a coinsurance rate of 80-20, and they have already met their deductible.
$900
What is the formula for calculating an insurance company payment in an indemnity plan?
charge - deductible - coinsurance
What is typically required of professional organizations?
continuing education sessions
Identify the type of HMO cost-containment method that requires providers to use a formulary.
controlling drug costs
Describe the role of a primary care physician (PCP) in an HMO.
coordinating patients' overall care
Identify the type of HMO cost-containment method that requires the patient to pay a copayment.
cost-sharing
Examine the list of services and determine which one would most likely be considered a non covered service
employment-related injuries
Courteous treatment of patients who visit the medical practice is an example of medical:
etiquette
When the coinsurance rate is stated, which number, the first or the second, describes the insurance company's percentage?
first
PPO members who use out-of-network providers may be subjected to:
higher copayments
Determine which of the following entities is not considered a provider.
insurance companies
Which of the following is an example of a private-sector payer?
insurance company
Under an insurance contract, the patient is the first party and the physician is the second party. Who is third party?
insurance plan
Identify the advantages offered to patients in managed care plans, as compared to indemnity insurance.
lower premiums,charges, and deductibles
Correctly relating a patient's condition and treatment refers to
medical necessity
The key to receiving coverage and payment from a payer is the payer's definition of:
medical necessity
Determine which of the following types of services a health plan will not pay for.
noncovered services
If a POS HMO member elects to receive medical services from out-of-network providers they usually
pay an additional cost
Which of the following conditions must be met before payment is made under an indemnity plan?
payment of premium, deductible, and coinsurance
Under a written insurance contract, the policyholder pays a premium, and the insurance company provides:
payments for covered medical services
Imagine you are a medical insurance specialist; illustrate the impact your ability to prepare accurate, timely claims can have on the practice.
preparing accurate and timely claims generally leads to full and timely reimbursement from the health plan
What kind of medical services are annual physical examinations and routine screening procedures?
preventive
What attributes should a medical insurance specialist possess to help lead to success?
professional appearance, practicing courtesy, good attendance, and attention to detail
The statement that "coding professionals should not change codes. . .to increase billings" is an example of:
professional ethics
A capitated payment amount is called a
prospective payment
Pick the most accurate definition of certification.
recognition of a superior level of skill by an official organization
Identify the type of HMO cost-containment method that requires patients to obtain approval for services before they receive the treatment.
requiring preauthorization for services
Identify the type of HMO cost-containment method that limits members to receiving services from the HMO's physician network.
restricting patients' choice of providers
Where do medical insurance companies summarize the payments they may make for medically necessary medical services?
schedule of benefits document
Practice management programs may be used for:
scheduling appointments, financial record keeping, and billing
Employers that offer health plans to employees without using an insurance carrier are:
self-funded (insured) health plans
Dependents of a policyholder may include his/her:
spouse and children
Out-of-pocket expenses must be paid by:
the insured
Choose the entity(ies) that may form agreements with an MCO.
the patient and provider
A patient ledger records:
the patient's financial transactions
Healthcare claims report data to payers about __________ and __________.
the patient; the services provided by the physician
How is coinsurance defined?
the percentage of each claim that the insured pays
What is a premium?
the periodic payment the insured is required to make to keep a policy in effect
In what format are healthcare claims sent?
Electronic and hard copy
Name the two components of a consumer-driven health plan (CDHP).
a health plan and a special "savings account"
Compare the choices below to determine which type of provider service would most likely NOT be covered by a health plan.
a medical procedure that is not included in a plan's benefits
Under a fee-for-service plan, the third-party payer makes a payment:
after medical services are provided
Name a benefit a provider usually gets from participation with a health plan.
an increased number of patients
In what ways can insurance policies be written?
an individual or group
Under an indemnity plan, typically a patient may use the services of:
any provider
When is a deductible paid?
before benefits begin
