Chapter 2: Health Ins. Models & Consumer Driven Health Plans

Question 1

A new patient is seen for a visit with a participating commercial carrier. CPT® code 99204 is billed for $200. The contracted fee for this carrier is $153.35. The patient has a 20% co-pay after a $1000 deductible, of which $500 has been met. How much will the patient owe?

Answer 1

$153.35 - since the ded has not been met, the contracted amount will be applied to the ded.

Question 2

A patient presenting for care does not have an insurance card and is billed CPT® code 99213 for $100. The patient pays $100 to the provider. A week later, the patient presents verification of coverage through Medicaid for this date of service. What process should be followed?

Answer 2

File a claim with Medicaid, a refund will be completed once the EOB is received

Question 3

A group contracts with a third-party administrator to manage paperwork. This group pays for the operation of the insurance plan and the costs of administration. What type of plan does this represent?

Answer 3

Self Funded ERISA - available to large groups
** Think, working at OSB and working through standard

Question 4

A Medicare patient is seen in the Internist’s office for a check-up. The office bills Medicare, but the patient receives the payment and the office must collect their fee from the patient. The office, by state law, can charge the patient a limiting charge that is 10 percent above the Medicare fee schedule amount. What type of Medicare provider is this physician?

Answer 4

Non-participating - doesnt accept assignment.

Question 5

Medicaid is overseen by who?

Answer 5

CMS

Question 6

What is an insurance plan that provides a gatekeeper to manage the patient’s healthcare?

Answer 6

HMO

Question 7

What components make up the Medicare Physician Fee Schedule?

Answer 7

Relative value units for physician work, practice expense, and professional liability insurance; the Geographical Practice Cost Index; and the conversion facto

Question 8

NPI is an abbreviation for a unique number that is required by HIPAA. What does NPI stand for

Answer 8

National Provider Identifier

Question 9

What is a disadvantage to capitation?

Answer 9

It involves total assumption of risk by the physician. they could end up losing money .

Question 10

Which type of HMO contracts with multiple specialty groups, individual practice groups, and individual physicians?

Answer 10

Network Model HMO

Question 11

Physician-Hospital Organizations (PHO), Management Service Organization (MSO) and Integrated Provider Organization (IPO) are examples of what type of healthcare models?

Answer 11

Integrated Delivery Systems = they are a network of providers and facilities that work together to offer joint healthcare services to its members

Question 12

When a patient is enrolled in an HMO, what are the responsibilities of the PCP?

Answer 12

Is responsible for:
- manage members treatment
- healthcare decisions and referrals
- in network specialists
- referrals for inpatient admission

Question 13

What are the 2022 Medicare deductible and co-insurance amounts for outpatient services on Part B?

Answer 13

$233 per year and 20% of the approved amount

Question 14

What Medicaid services are eligible for reimbursement for an individual that is not a citizen or does not have eligible immigration status?

Answer 14

Emergency services.

Question 15

What organizations are included in MCOs?

Answer 15

EPOs, HMOs, IDS, PPOs, and Triple Option Plans

Question 16

A patient is age 65 and Medicare eligible. The patient signs up for a Medicare Managed Care plan. When the patient presents for care, where are claims sent?

Answer 16

Managed Care Plan = Advantage Plan

Question 17

A family practitioner sees a Medicare patient and bills a 99213. This provider has opted-out of Medicare. His fee for the service is $125.00. Medicare’s approved amount is $73.08, and the patient has met $0 of his deductible. What can the provider bill the patient?

Answer 17

$125 - the provider opted out so there isnt a limit to how much they can charge their patients.
Patient is responsible for payment in full

Question 18

A Medicaid patient presents for services on the first day of the month. He has a $50 spenddown and has had no services this month. The visit for today was $100.00. If the patient wants to be covered as long as possible from today’s visit, what can he do?

Answer 18

A bill that is larger than a spenddown may be used to meet multiple months spenddown. they should turn the receipt in to their caseworker and be eligible for 2 months worth of coverage

Question 19

What are some common types of group insurances available?

Answer 19

Fully Insured Employer Group
Small Employer Group
Self Funded ERISA
Association Group

Question 20

Which Group Insurance Plan represents when an employer assumes financial responsibility for medical claims for their employees?

Answer 20

Fully Insured Employer Group

Question 21

Which group insurance plan represents when insurance companies group certain industries together and gather smaller employers to form a large group?

Answer 21

Small Employer Group

Question 22

Which group insurance plan is offered by a different type of group other than an employer?

Answer 22

Association Group
* think when you get life ins offered through robins financial

Question 23

Participating vs Non Participating Providers

Answer 23

Par - is contracted with payer to agree to accept assignment and submit claims for services provided. contractual adjustment/writeoff difference
NonPar - doesnt accept assignment, may bill the patient for the difference between amount billed and amount paid by payer

Question 24

Which program offers free health benefits counseling to Medicare beneficiaries, families, or caregivers?

Answer 24

SHIP = State Health Insurance Assistance Program

Question 25

Who was the Health Maintenance Organization Act of 1973 signed by?

Answer 25

President Nixon on December 29, 1973

Question 26

What did the Health Maintenance Organization Act of 1973 do?

Answer 26

- Authorized $375 million over 5 years to grow - Required employers to offer an HMO option

Question 27

What are the 5 HMO Models?

Answer 27

1. Group Model HMO 2. Staff Model HMO 3. Network Model HMO 4. Individual/Independent Practice Association(IPA) 5. Mixed Model HMO

Question 28

Which HMO Model combines features of the IPA and group HMO models offering the biggest variety of choices and covers the largest geographic area?

Answer 28

Mixed model HMO

Question 29

Which HMO Model contracts with independent physicians who maintain their office and provider services to HMO and Non HMO patients, receiving a fixed amount per patient?

Answer 29

Individual/Independent Practice Association(IPA) -Open Panel HMO with IPA, can make out of network referrals but may not cover much

Question 30

Which HMO Model employs the physicians on salary to provide care to the members in the clinics and other facilities owned by the HMO?

Answer 30

Staff Model HMO - Closed Panel HMO -ONLY HMO Patients

Question 31

Which HMO Model contracts with a multi-specialty group that provides care to the members?

Answer 31

Group Model HMO - pays in bulk - HMO or non HMO patients

Question 32

What is an umbrella term for organizations that are affiliated with or own hospitals, physician groups, and other providers which provide a wide range of coordinated health services?

Answer 32

MCOs Managed Care Organizations

Question 33

Which MCO organization has entered into contracts with medical care providers or groups of medical care providers to provide healthcare services to members?

Answer 33

EPO - Exclusive Provider Organization

Question 34

Managed Care Organizations (MCO) combine the functions of health insurance, delivery of care, and administration. Which participating provider networks are included?

Answer 34

EPO HMO IDS PPO Triple Action Plan

Question 35

Which MCO organization is a network of affiliated facilities and providers that work together to offer joint healthcare services to members and what are the 4 models?

Answer 35

Integrated Delivery Systems (IDS) 1. Physician Hospital Org. (PHO) 2. Management Service Organization (MSO) 3. Group Practice Without Walls (GPWW) 4. Integrated Provider Organization (IPO)

Question 36

Which IDS organization is owned by hospitals and physician groups that work together to develop improved method of healthcare?

Answer 36

Physician-Hospital Organization (PHO)

Question 37

Which IDS organization is a business that provides nonclinical services to providers? (ex: practice management and coding)

Answer 37

MSO - Managed Service Organization

Question 38

Which IDS organization is a medical practice formed to share economic risk, expenses, and marketing efforts?

Answer 38

GPWW - Group Practice Without Walls - Physicians retain sep. offices and finances

Question 39

Which IDS organization is a corporate umbrella for the management of diversified healthcare delivery system?

Answer 39

Integrated Provider Organization (IPO) * they are involved in financial decision making

Question 40

Which MCO organization is a type of insurance plan that allows members to choose the doctors and hospitals they want to visit from providers within the network?

Answer 40

PPO Preferred Provider Organization

Question 41

Which MCO organization is usually operated by a single insurance plan or joint venture among two or more insurance payers?

Answer 41

Triple Options Plan - allows an insurer to administer 3 different healthcare plans so that members may select the benefit options they want

Question 42

An internist sees a 20-year-old patient for an office visit. The patient needs to see an endocrinologist for a consultation regarding her diabetes. The internist is a participating provider in her plan. She can choose any provider she wishes for her consultations, but she will save money if she sees a specialist that is in her network. She does not require a referral for her consultation. What type of insurance does the patient have?

Answer 42

PPO

Question 43

Under the Patient Protection and Affordable Care Act (ACA), what is banned?

Answer 43

-Lifetime limits -limit, deny, or charge more for benefits due to preexisting conditions, health status or gender

Question 44

Which insurance is a healthcare benefit program for military personnel in all seven uniformed branches?

Answer 44

Tricare

Question 45

A patient has receipts for her dental cleaning, vision exam, and contact lenses. Her employer has set up special accounts for each employee, there is no limit to the amount the employer can contribute and the balances roll over from year to year. What type of account is this?

Answer 45

Traditional Healthcare Reimbursement Arrangement (HRA)

Question 46

What does an NPI not do?

Answer 46

1. ensure provider licenses or credentialed 2. guarantee payment by health plan 3. enroll provider in health plan 4. make provider a covered provider 5. provider to be HIPPA compliant 6. change or replace Medicare enrollment or certification process

Question 47

A patient presents to be seen in the office. He does not pay at the time the services are rendered as the provider is his primary care provider, or gatekeeper. The large group practice has 800 covered members under this plan as is paid on a monthly basis with a set amount that is based on the number of members covered and their ages. What type of plan is this?

Answer 47

Capitation