CBCS Health Insurance 1 — Questions and Answers
Question 1: What is coinsurance in a health insurance policy?
- A fixed amount the patient pays for a covered healthcare service
- A percentage of the cost of a covered healthcare service that the patient pays after the deductible has been met (Correct answer)
- The total cost of the healthcare service covered by insurance
- The amount the insurance company pays for a covered healthcare service
Correct answer: A percentage of the cost of a covered healthcare service that the patient pays after the deductible has been met
Coinsurance is the share of the cost of a covered healthcare service that you pay, calculated as a percentage. This payment typically begins after your deductible has been met, meaning the insurance company pays a portion (e.g., 80%), and you pay the remaining percentage (e.g., 20%) until your out-of-pocket maximum is reached. It is distinct from a copayment, which is a fixed fee.
Question 2: How are claims typically handled in an indemnity health insurance plan?
- The healthcare provider bills the insurance company directly, and the patient pays nothing
- The patient pays the healthcare provider upfront and then files a claim for reimbursement (Correct answer)
- The patient and provider share the cost equally
- The insurance company pays the provider directly and sends a bill to the patient
Correct answer: The patient pays the healthcare provider upfront and then files a claim for reimbursement
In an indemnity health insurance plan, also known as a fee-for-service plan, the patient typically pays the healthcare provider directly for services rendered. The patient then submits a claim to their insurance company for reimbursement. This model offers more flexibility in choosing providers but places the initial financial burden on the patient.
Question 3: What is the typical payment structure for providers in an HMO?
- Fee-for-service
- Capitation (Correct answer)
- Pay-for-performance
- Retainer fee
Correct answer: Capitation
In a Health Maintenance Organization (HMO), providers are often paid through a capitation model. Under capitation, providers receive a fixed monthly payment per enrolled patient, regardless of how many services the patient uses. This payment structure incentivizes providers to focus on preventive care and manage costs efficiently, as they bear the financial risk for patient care.
Question 4: What does "underpayment" refer to in the context of medical billing and coding?
- When the insurance company pays more than the billed amount
- When the insurance company pays less than the billed amount (Correct answer)
- When the patient pays more than the copay amount
- When the billed amount is adjusted for a contractual agreement
Correct answer: When the insurance company pays less than the billed amount
Underpayment in medical billing occurs when the amount an insurance company pays for a service is less than the amount the provider billed. This can happen due to various reasons, such as incorrect coding, contractual adjustments, or issues with patient eligibility. Billing specialists must identify and address underpayments to ensure the practice receives appropriate reimbursement.
Question 5: Which insurance plan type requires members to choose a primary care physician (PCP) and get referrals to see specialists?
- PPO
- HMO (Correct answer)
- POS
- EPO
Correct answer: HMO
Health Maintenance Organizations (HMOs) typically require members to choose a primary care physician (PCP) within the network. The PCP acts as a gatekeeper, coordinating all of the patient's care and providing referrals to specialists if needed. This structure aims to manage costs and ensure integrated care within a defined network.
CBCS Health Insurance 1
What is coinsurance in a health insurance policy?