HCMG Exam 3 Questions and Correct Answers Latest Update 2025 Rated A+

HCMG Exam 3 Questions and Correct Answers Latest Update 2025 Rated A+ What is the significance of surprise medical bills in each type of insurance model? - Answers In public insurance (medicare/medicaid), surprise medical bills are not an issue here because medicare and medicaid have already negotiated with doctors across the board. In private insurance, surprise medical bills show up here. Employer negotiates with insurance company to determine how much the insurance company will contribute, how much you will contribute out of paycheck What are the three types of private insurance models? - Answers HMO - If you go to out of network doctor, you have to pay whatever doctor charges you → no out of network care paid for by an insurance company PPO - If you go to out of network doctor, you will pay a lesser rate than what you have to pay without insurance, but you have to pay more than what you would if you went to in network doctor Full Indemnity - You pay a premium (more than HMO and PPO premium), but you can see whoever you want What are some research questions associated with surprise medical bills? - Answers Positive: What is true, what is factual Is this rare or frequent? Unique to a situation? Does it happen differently in different health care settings? Does it happen differently in different locations? Normative - what is the norm? What should be the norm Why is it happening? What can we do about it as consumers and policy makers? Defining a Surprise Out of Network Bill - Answers To define a surprise medical bill within a quantitative research question - EMPIRICALLY CHALLENGING. Inference and data allows us to determine if a bill is a surprise medical bill. What type of data do researchers look at to determine surprise out of network bill? - Answers Analyze the data such as Date, time, Hospital Bill Type of procedure, the cost of the procedure, code, the insurance company (what they have contributed, and what expected contribution will be) So bill will have total cost, cost insurer will pay, cost you have to pay If a doctor negotiates with an insurance company - they are considered in network Treatment categories that are used to classify cases by potential surprise medical bill status - Answers For ED (inpatient and outpatient) and elective procedures (inpatient) services: If the hospital and primary doctor are in network, and other doctor or services is out of network If hospital is in network, primary doctor is unidentified in the data, but other doctor or services are out of network For ED (inpatient and outpatient): If hospital is in network, and primary doctor is out of network or there is an ambulance claim Percentage of hospital cases with potential surprise medical bills - Answers In 2007, 30% of patients who were in the ED as an inpatient encountered a surprise medical bill It has decreased as years go on but percentage is still high There are a lot of mergers, there are less people and less groups for insurance company to negotiate with, so less time to spend to negotiate with all these small providers, so able to contract more doctors, more doctors in network, less chances of encountering a bill from a physician that is out of network. Surprise Medical Bills by Type of Category (diagnostic category) - Answers There are highe