1
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CHFP Module 1 Certification Test
Questions and Answers (100% Correct
Answers) Already Graded A+
is a pre-determined amount that the patient pays before the
insurer begins to pay for services—Ans: deductible
a percentage of the insurance payment amount that is paid by
the patient, along with the amount paid by the insurer.—Ans:
© 2025 Assignment Expert
coinsurance
a flat amount that the patient pays at each time of service—Ans:
copayment
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payment also includes amounts for services that are not included
in the patient's benefit design and amounts for services balance
billed by out-of-network providers. Payments typically does not
include premium sharing by the patient.—Ans: Out-of-pocket
payment
The amount payable out of pocket for healthcare services, which
may includes deductibles, copayments, coinsurance, amounts
payable by the patient for services that are not included in the
patient's benefit design, and amounts "balance billed" by out-of-
network providers. Health insurance premiums constitute a
separate category of healthcare costs for patients, independent
of healthcare utilization.—Ans: Cost (to the patient)
The expense (direct and indirect) incurred to deliver healthcare
services to patients.—Ans: Costs (to the provider)
The amount payable to the provider (or reimbursable to the
patient) for services rendered.—Ans: Cost (to the health
plan/insurer)
The expense related to provided health benefits (premiums or
claims paid)—Ans: Cost (to the employer)
, 2
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The dollar amount a provider sets for services rendered before
negotiating any discounts. The charge can be different from the
amount paid.—Ans: Charge
The total amount a provider expects to be paid by health
plans/payers and patients for healthcare services.—Ans: Price
An organization that negotiates or sets rates for provider services,
collects revenue through premium payments or tax dollars,
processes provider claims for service, and pays provider claims
using collected premium or tax revenues.—Ans: Health
Plan/Payer
An entity, organization, or individual that furnishes a healthcare
© 2025 Assignment Expert
service.—Ans: Provider
Occurs when a healthcare provider bills a patient for charges
(other than copayments, coinsurance or any amounts that may
remain on the patient's annual deductible) that exceed the
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health plan's payment for a covered service. In-network providers
are contractually prohibited from balance billing health plan
members, but balance billing by out-of-network providers is
common.—Ans: Balance Billing
In healthcare, readily available information on the price of
healthcare services that, together with other information, helps
define the value of those services and enables patients and other
care purchasers to identify, compare and choose providers that
offer the desired level of value—Ans: Price Transparency
The quality of a healthcare service in relation to the total price
paid for the service by care purchasers.—Ans: Value
the flow of money between the patient, the insurer, and the
provider of healthcare services—Ans: Revenue Cycle
function between a healthcare facility or physician and an insurer
is one of the most important resource management challenges in
today's healthcare industry.—Ans: Billing and Collection
An older term used to describe payment by an insurer to a
healthcare facility or physician. This term is used because a
, 3
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physician or healthcare facility provider render services to a
patient and then submits claims a claim to an insurer. The
healthcare facility or physician waits for processing of that claim
by the insurer, and ultimately recieves payment, a determination
of payment or a denial by the insurer. Today it is more common to
use the term payment.—Ans: Reimbursement
The price set by a healthcare facility or physician for their services
is referred to as—Ans: Charges or Billed Charges
The charges by a healthcare facility or physician represent the
retail price and are usually compiled in a price listing known as—
Ans: Chargemaster
© 2025 Assignment Expert
a charge-based payment mechanism in which a provider is paid
either list price (full charges) or a percentage of charges (full
charges less a discount) for the specific services rendered.—Ans:
Fee-for-service
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What does fee for service payment provides?—Ans: more units of
service in order to receive more payments.
Why do Healthcare Facilities set Retail prices significantly above
rates actually paid by commercial insurers or the government?—
Ans: 1. Access to Contracted Payment Rates.
-Rare not all insurers participate in provider networks that give
them access to contracted payment rates. Some auto insurers,
liability insurers or companies providing travel insurance to visitors
from abroad still pay a provider's full charges.
2. Percent-of-Charge Contracts
-In markets with little competition, percent-of-charge contracts
are still common. The higher the price, the higher the percent-of-
charge payment, unless the contract limits a provider's annual
price increases.
3. Outlier Provisions
-Some insurance contacts contain an outlier provision that entitles
providers to an additional payment (a lump-sum payment or a
, 4
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percentage of actual charges above a threshold) for particularly
sick and high-cost patients.
What is the use and benefits of Cost Based Payments?—Ans: The
only use of this method today is in a limited set of small, rural
healthcare facilities known as critical access hospitals. This
mechanism has rarely been used for physicians. Cost-based
payment calls for the insurer to pay the healthcare provider based
on the costs of providing services, with a nominal allowance for
margin.
What is the Medicare program began with a payment
mechanism to healthcare facilities that has since been nearly
eliminated from the healthcare industry ——Ans: Cost based
© 2025 Assignment Expert
Payment
Which of the following would benefit the most from a cost-based
payment method?—Ans: The healthcare provider
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That's right! Let's understand how.
The payment mechanism is advantageous for healthcare
providers, as there is a higher likelihood that all costs will be paid,
and there is no incentive to be efficient in providing care, since
costs will be reimbursed by the insurer. The rapid escalation of
healthcare costs in the U.S. after the start of cost-based payment
in Medicare and Medicaid programs led to the implementation of
the Prospective Payment System (PPS) of paying acute care
healthcare providers for inpatient services in 1983 and outpatient
services in 2000. Since then, CMS has introduced prospective
payment systems for most other types of institutional healthcare
providers
Cost-Based payment decreased need for providers to be
efficient.
Mountainside Health Plan is evaluating its payment of hospitals in
its current service area. It is looking to reduce its costs per patient
For Expert help and assignment solutions, +254707240657
CHFP Module 1 Certification Test
Questions and Answers (100% Correct
Answers) Already Graded A+
is a pre-determined amount that the patient pays before the
insurer begins to pay for services—Ans: deductible
a percentage of the insurance payment amount that is paid by
the patient, along with the amount paid by the insurer.—Ans:
© 2025 Assignment Expert
coinsurance
a flat amount that the patient pays at each time of service—Ans:
copayment
Guru01 - Stuvia
payment also includes amounts for services that are not included
in the patient's benefit design and amounts for services balance
billed by out-of-network providers. Payments typically does not
include premium sharing by the patient.—Ans: Out-of-pocket
payment
The amount payable out of pocket for healthcare services, which
may includes deductibles, copayments, coinsurance, amounts
payable by the patient for services that are not included in the
patient's benefit design, and amounts "balance billed" by out-of-
network providers. Health insurance premiums constitute a
separate category of healthcare costs for patients, independent
of healthcare utilization.—Ans: Cost (to the patient)
The expense (direct and indirect) incurred to deliver healthcare
services to patients.—Ans: Costs (to the provider)
The amount payable to the provider (or reimbursable to the
patient) for services rendered.—Ans: Cost (to the health
plan/insurer)
The expense related to provided health benefits (premiums or
claims paid)—Ans: Cost (to the employer)
, 2
For Expert help and assignment solutions, +254707240657
The dollar amount a provider sets for services rendered before
negotiating any discounts. The charge can be different from the
amount paid.—Ans: Charge
The total amount a provider expects to be paid by health
plans/payers and patients for healthcare services.—Ans: Price
An organization that negotiates or sets rates for provider services,
collects revenue through premium payments or tax dollars,
processes provider claims for service, and pays provider claims
using collected premium or tax revenues.—Ans: Health
Plan/Payer
An entity, organization, or individual that furnishes a healthcare
© 2025 Assignment Expert
service.—Ans: Provider
Occurs when a healthcare provider bills a patient for charges
(other than copayments, coinsurance or any amounts that may
remain on the patient's annual deductible) that exceed the
Guru01 - Stuvia
health plan's payment for a covered service. In-network providers
are contractually prohibited from balance billing health plan
members, but balance billing by out-of-network providers is
common.—Ans: Balance Billing
In healthcare, readily available information on the price of
healthcare services that, together with other information, helps
define the value of those services and enables patients and other
care purchasers to identify, compare and choose providers that
offer the desired level of value—Ans: Price Transparency
The quality of a healthcare service in relation to the total price
paid for the service by care purchasers.—Ans: Value
the flow of money between the patient, the insurer, and the
provider of healthcare services—Ans: Revenue Cycle
function between a healthcare facility or physician and an insurer
is one of the most important resource management challenges in
today's healthcare industry.—Ans: Billing and Collection
An older term used to describe payment by an insurer to a
healthcare facility or physician. This term is used because a
, 3
For Expert help and assignment solutions, +254707240657
physician or healthcare facility provider render services to a
patient and then submits claims a claim to an insurer. The
healthcare facility or physician waits for processing of that claim
by the insurer, and ultimately recieves payment, a determination
of payment or a denial by the insurer. Today it is more common to
use the term payment.—Ans: Reimbursement
The price set by a healthcare facility or physician for their services
is referred to as—Ans: Charges or Billed Charges
The charges by a healthcare facility or physician represent the
retail price and are usually compiled in a price listing known as—
Ans: Chargemaster
© 2025 Assignment Expert
a charge-based payment mechanism in which a provider is paid
either list price (full charges) or a percentage of charges (full
charges less a discount) for the specific services rendered.—Ans:
Fee-for-service
Guru01 - Stuvia
What does fee for service payment provides?—Ans: more units of
service in order to receive more payments.
Why do Healthcare Facilities set Retail prices significantly above
rates actually paid by commercial insurers or the government?—
Ans: 1. Access to Contracted Payment Rates.
-Rare not all insurers participate in provider networks that give
them access to contracted payment rates. Some auto insurers,
liability insurers or companies providing travel insurance to visitors
from abroad still pay a provider's full charges.
2. Percent-of-Charge Contracts
-In markets with little competition, percent-of-charge contracts
are still common. The higher the price, the higher the percent-of-
charge payment, unless the contract limits a provider's annual
price increases.
3. Outlier Provisions
-Some insurance contacts contain an outlier provision that entitles
providers to an additional payment (a lump-sum payment or a
, 4
For Expert help and assignment solutions, +254707240657
percentage of actual charges above a threshold) for particularly
sick and high-cost patients.
What is the use and benefits of Cost Based Payments?—Ans: The
only use of this method today is in a limited set of small, rural
healthcare facilities known as critical access hospitals. This
mechanism has rarely been used for physicians. Cost-based
payment calls for the insurer to pay the healthcare provider based
on the costs of providing services, with a nominal allowance for
margin.
What is the Medicare program began with a payment
mechanism to healthcare facilities that has since been nearly
eliminated from the healthcare industry ——Ans: Cost based
© 2025 Assignment Expert
Payment
Which of the following would benefit the most from a cost-based
payment method?—Ans: The healthcare provider
Guru01 - Stuvia
That's right! Let's understand how.
The payment mechanism is advantageous for healthcare
providers, as there is a higher likelihood that all costs will be paid,
and there is no incentive to be efficient in providing care, since
costs will be reimbursed by the insurer. The rapid escalation of
healthcare costs in the U.S. after the start of cost-based payment
in Medicare and Medicaid programs led to the implementation of
the Prospective Payment System (PPS) of paying acute care
healthcare providers for inpatient services in 1983 and outpatient
services in 2000. Since then, CMS has introduced prospective
payment systems for most other types of institutional healthcare
providers
Cost-Based payment decreased need for providers to be
efficient.
Mountainside Health Plan is evaluating its payment of hospitals in
its current service area. It is looking to reduce its costs per patient
