Healthcare Reimbursement Chapter 6
Test Questions and Correct Answers
Balance billing ✅Allowing the provider to charge the patient the difference of the
allowed amount from insurance
Allowed charge ✅The allowable charge, or payment set by the health care plan for
each covered service. This is the maximum fee the health plan will pay for that service
or procedure.
What are five disadvantages of indemnity plans? ✅Must meet deductible. Patient pays
a larger portion of cost. Limited coverage. Preventative care sell them covered. Patient
statements must be prepared and mailed. Collections difficult and expensive. Patient
receives all communication from insurance practice and doesn't know if there are
penalties.
When a patient has an indemnity plan and Medicaid who is the primary payer?
✅Indemnity plans are the primary payers in most cases.
What plans traditionally were fee-for-service? ✅Indemnity plans
What are the three methods used by payers to set up fees? ✅Usual, customary, and
reasonable. UCR.
Relative value scale RVS.
Resource base relative value scale RBRVS.
What does the U in UCR stand for, and what does it mean? ✅Usual. Usual fee of
individual physicians in the community.
What does the C in UCR stand for, and what does it mean? ✅Customary. Customary
fee charged by most physicians in the community.
What does The R in UCR stand for, and what does it mean? ✅Reasonable.
Reasonable fee for the service.
What is fee profiling? ✅The insurance industry gathers data, the lowest rate physicians
will except, which is lower than the standard fee schedule. Each payer tracks the
standard fee submitted on claims by physicians across the country. Payers also tracked
the average payments accepted by individual physicians for each procedure code
number. They use this data to establish the UCR rate.
, What course of action do patients have if indemnity plans do not reimburse the proper
amount? ✅Include list of fees in appeal to indemnity plan. Plan will usually reimburse
more. If not, patient can file complaint with the state insurance commissioner.
What are some out-of-pocket expenses that a patient might have to pay?
✅Deductibles. Copayments. Coinsurance. Excluded and over limit services. Balance
billing.
PAR Provider, In-network provider ✅A provider that excepts the payment from the
insurance carrier as payment in full for the covered services. Differences are written off.
Nonpar out of network ✅Providers that may build a patient for the difference between
the insurance payment in the allowed charge.
What is the UCR determined by? ✅The UCR is determined by insurers according to
research on the usual, customary, and reasonable charge for procedures.
Cap, or capitation rate ✅The fixed payment for each plan member in an HMO.
What are some of the advantages of hmos? ✅Do you not have to advertise for HMO
patients. Guaranteed patience. Known fee schedules. Service is authorized are usually
paid. Patients more likely to seek care early. Most preventative medicine is covered.
Patients out of pocket expenses are low.
Which plan must me a high deductible before the health plan can make a payment?
✅Consumer driven health plan
What is the goal of an effective patient check out procedure? ✅The patient
understands financial responsibility
What summarizes the services and charges for that day as well as any payments the
patient made? ✅Walk out receipt
If the participating providers charge is higher than the allowed amount, which amount is
the basis for reimbursement? ✅Allowed amount
Before the prayer begins to pay benefits, what must a policyholder pay annually under a
typical indemnity plan? ✅Deductible
What percentage of the allowed charge is the patient responsible for through the
original Medicare plan after the patient meets their annual deductible? ✅20%
Fees that physicians charge to most of their patients most of the time under typical
conditions ✅Usual fees
Test Questions and Correct Answers
Balance billing ✅Allowing the provider to charge the patient the difference of the
allowed amount from insurance
Allowed charge ✅The allowable charge, or payment set by the health care plan for
each covered service. This is the maximum fee the health plan will pay for that service
or procedure.
What are five disadvantages of indemnity plans? ✅Must meet deductible. Patient pays
a larger portion of cost. Limited coverage. Preventative care sell them covered. Patient
statements must be prepared and mailed. Collections difficult and expensive. Patient
receives all communication from insurance practice and doesn't know if there are
penalties.
When a patient has an indemnity plan and Medicaid who is the primary payer?
✅Indemnity plans are the primary payers in most cases.
What plans traditionally were fee-for-service? ✅Indemnity plans
What are the three methods used by payers to set up fees? ✅Usual, customary, and
reasonable. UCR.
Relative value scale RVS.
Resource base relative value scale RBRVS.
What does the U in UCR stand for, and what does it mean? ✅Usual. Usual fee of
individual physicians in the community.
What does the C in UCR stand for, and what does it mean? ✅Customary. Customary
fee charged by most physicians in the community.
What does The R in UCR stand for, and what does it mean? ✅Reasonable.
Reasonable fee for the service.
What is fee profiling? ✅The insurance industry gathers data, the lowest rate physicians
will except, which is lower than the standard fee schedule. Each payer tracks the
standard fee submitted on claims by physicians across the country. Payers also tracked
the average payments accepted by individual physicians for each procedure code
number. They use this data to establish the UCR rate.
, What course of action do patients have if indemnity plans do not reimburse the proper
amount? ✅Include list of fees in appeal to indemnity plan. Plan will usually reimburse
more. If not, patient can file complaint with the state insurance commissioner.
What are some out-of-pocket expenses that a patient might have to pay?
✅Deductibles. Copayments. Coinsurance. Excluded and over limit services. Balance
billing.
PAR Provider, In-network provider ✅A provider that excepts the payment from the
insurance carrier as payment in full for the covered services. Differences are written off.
Nonpar out of network ✅Providers that may build a patient for the difference between
the insurance payment in the allowed charge.
What is the UCR determined by? ✅The UCR is determined by insurers according to
research on the usual, customary, and reasonable charge for procedures.
Cap, or capitation rate ✅The fixed payment for each plan member in an HMO.
What are some of the advantages of hmos? ✅Do you not have to advertise for HMO
patients. Guaranteed patience. Known fee schedules. Service is authorized are usually
paid. Patients more likely to seek care early. Most preventative medicine is covered.
Patients out of pocket expenses are low.
Which plan must me a high deductible before the health plan can make a payment?
✅Consumer driven health plan
What is the goal of an effective patient check out procedure? ✅The patient
understands financial responsibility
What summarizes the services and charges for that day as well as any payments the
patient made? ✅Walk out receipt
If the participating providers charge is higher than the allowed amount, which amount is
the basis for reimbursement? ✅Allowed amount
Before the prayer begins to pay benefits, what must a policyholder pay annually under a
typical indemnity plan? ✅Deductible
What percentage of the allowed charge is the patient responsible for through the
original Medicare plan after the patient meets their annual deductible? ✅20%
Fees that physicians charge to most of their patients most of the time under typical
conditions ✅Usual fees
