Question 1

The amount paid to a provider monthly to provide health care services to an employee is:

Accepted Answer

Capitation is a payment arrangement in which a provider is paid a fixed amount per patient or member of a health plan for a specified period of time, regardless of how many services are provided. This is often used in managed care plans, such as HMOs. Premiums (A) are the amount paid by the employee or employer to an insurance company to maintain coverage. Copayment (C) is a cost-sharing arrangement where the patient pays a fixed amount for each service received. Deductible (D) is the amount a patient must pay before insurance coverage begins.

Question 2

Determining who is responsible for health claim payments is known as:

Accepted Answer

Coordination of benefits (COB) is the process of determining which health insurance plan pays first and which pays second when a patient is covered by more than one plan. This helps avoid duplicate payments and ensures that the patient's out-of-pocket costs are minimized. COB typically involves determining the primary and secondary payers and may involve negotiations between insurance companies.

Question 3

With EPOs all of the following are true except:

Accepted Answer

EPOs (Exclusive Provider Organizations) are a type of managed care plan where patients must select their care providers from those in the network. If a patient chooses to go outside the network, services may not be covered. EPOs are regulated by state insurance law. However, patients can choose their physician or hospital from within the network in EPOs. Therefore, option B is false.

Question 4

The _____________ calculates risk and helps set premiums.

Accepted Answer

An actuary is a professional who specializes in assessing and managing risk, particularly in the insurance industry. One of their main functions is to calculate risk and determine appropriate insurance premiums based on various factors such as age, health status, occupation, and more.

Question 5

This organization negotiates and manages provider's contracts.

Accepted Answer

The answer of This organization negotiates and manages provider's contracts.
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Question 6

Premiums are the:

Accepted Answer

Premiums are the fee paid by employers and employees to the insurance company in exchange for health coverage.

Question 7

All of the following are true except:

Accepted Answer

The answer of All of the following are true except:
...

Question 8

A third-party payer may be:

Accepted Answer

A third-party payer is any entity other than the patient or healthcare provider that pays for all or part of the cost of medical care. This can include insurance companies, government agencies such as Medicare or Medicaid, and even service providers such as hospitals or clinics that offer financial assistance programs. Therefore, all of the choices (A, B, and C) are correct.

Question 9

A policy is:

Accepted Answer

The answer of A policy is:
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Question 10

A PPO:

Accepted Answer

A PPO is a delivery network that contracts with healthcare providers to offer services to its members at discounted rates. PPOs do not receive premiums or assume financial risk themselves, but instead contract with insurance companies or employers who provide coverage to their members. When a preferred provider is used, the cost of services is reduced, making it a more affordable option for the patient. Therefore, all the given options (A, B, and C) are correct.

Question 11

John is known as a(n) _______________ in his HMO.

Accepted Answer

The answer of John is known as a(n) _______________ in...

Question 12

The copayment is the:

Accepted Answer

The copayment is the portion of services paid by the patient. It is a set amount that the patient is responsible for paying at the time the service is received, regardless of the actual cost of the service. It is typically a small amount, such as $10 or $20, and is meant to incentivize patients to use healthcare services in a responsible and cost-effective manner. The copayment is separate from deductibles and coinsurance, which are also forms of cost-sharing between the patient and the insurance company.

Question 13

A deductible is the:

Accepted Answer

A deductible is the amount paid by the patient before the third-party payer begins to pay. This means that the patient is responsible for paying a certain amount of their medical expenses out of pocket, before their insurance coverage kicks in.

Question 14

An enrollment period is a:

Accepted Answer

An enrollment period is a specific time when employees can make changes to their health insurance or other benefits plan, such as changing providers or adding dependents. It is not a binding contract between the payer and employee or employer.

Question 15

Third-party payers are covered by both state and federal regulations. Two of the federal regulations are:

Accepted Answer

ERISA (Employee Retirement Income Security Act) and HIPAA (Health Insurance Portability and Accountability Act) are two federal regulations that cover third-party payers.

COBRA (Consolidated Omnibus Budget Reconciliation Act) is also a federal regulation but it primarily deals with continuation of health coverage after specific qualifying events, rather than regulating third-party payers. PPO (Preferred Provider Organization) and EPO (Exclusive Provider Organization) are types of health insurance plans, not federal regulations.

ERICA is not a federal regulation and therefore not a valid answer choice.

Question 16

Health insurance is:

Accepted Answer

Health insurance encompasses various forms, including PPOs (Preferred Provider Organizations) and HMOs (Health Maintenance Organizations), and fundamentally involves shifting the risk of loss from an individual to an insurance provider.

Question 17

John's recent physician office visit was not paid by the insurance company. It was his first claim of the year. The claim totaled $200. The reason the claim was denied was likely related to John's:

Accepted Answer

Since it was John's first claim of the year and was not paid by the insurance company, it is likely that he had not met his deductible yet. The deductible is the amount of money that the insured must pay out of pocket before the insurance company starts paying for the medical expenses.

Question 18

The typical fee charged by providers in a geographic area is known as:

Accepted Answer

The typical fee charged by providers in a geographic area is known as usual, customary, and reasonable (UCR). This term is used by insurance companies to determine the amount of reimbursement for medical services based on what other providers in the same area are charging for similar services. The UCR fee is also known as the prevailing fee or the fair and reasonable fee. Therefore, the best choice is B, usual, customary, and reasonable.

Question 19

An HMO contracts with more than one group practice for service in which arrangement?

Accepted Answer

A Network HMO contracts with more than one group practice to provide medical services to members. Staff model HMO only contracts with one group practice. An IPA (Independent Practice Association) is a type of HMO that contracts with individual physicians and small group practices, rather than large group practices. PPO is a different type of managed care organization that allows members to choose from a network of providers, but also allows them to see out-of-network providers for a higher cost.

Question 20

A ______________________ is a system where payment is made in advance of services being provided.

Accepted Answer

A prepaid health plan is a system where payment is made in advance of services being provided, typically with a set fee or monthly premium. This can help individuals budget for healthcare expenses and avoid unexpected costs.

Quiz 3: The Payment Process: Insurance and Third-Party Payers