CPAR Exam Questions and Correct Answers

(ABN)Advanced beneficiary notice Ans: advanced notice that the patient may have to pay for lab testing that medicare will not cover. Insurance Ans: a way of reducing a person's exposure to risk of loss because another party (insurance company) assumes the risk. Reimbursement Ans: the compensation or repayment for healthcare services. First party Ans: the patient or the person responsible for the healthcare bill Second party Ans: the physician, hospital, clinic, nursing home, or other healthcare entity that rendered the care; called providers because they provide health care. Third party Ans: the insurance company that pays the second party (provider) for the services rendered to the first party (patient). Fee Ans: a set amount or a set price Charges Ans: what a healthcare provider has established as a fee for service Claim Ans: a list of the fees or charges for each service submitted to a third-party payer (insurance company) for payment Clean claim Ans: a request for payment submitted to a third-party payer that contains no errors in the data submitted Fee-for-service reimbursement Ans: provider receives payment for each service rendered Fee schedule Ans: a pre-established list of set fees that the third-party payer will allow for payment. UCR Ans: stands for usual, customary, and reasonable Usual Ans: refers to the provider's usual fee Customary Ans: refers to the customary fee in the community Reasonable Ans: refers to the reasonable fee for the situation Managed care Ans: the various forms of managed care include HMOs (health maintenance organizations), EPOs (exclusive provider organizations), POS (point-of service) plans, and PPOs (preferred provider organizations). Episode-of-care reimbursement Ans: the providers receive one lump sum for all of the services provided Capitation Ans: third-party payer reimburses provider a fixed, per-capita amount for a specified perio