This replaced the old customary prevailing and reasonable CPR payment system

This replaced the old customary prevailing and

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for physician services and other types of services. This replaced the old “customary, prevailing, and reasonable” (CPR) payment system. The MPFS is funded by Part B and is comprised of resource costs associated with physician work, practice expense, and professional liability insurance, with each of these three elements assigned a Relative Value Unit (RVU). These RVUs are adjusted based on the Geographical Practice Cost Index (GPCI) associated with various geographic areas for different medical costs and wage differentials. These factors are multiplied by a conversion factor. Question 8 A new patient is seen for a visit with a participating commercial carrier. Code 99204 is billed for $200. The contracted fee for this carrier is $153.35. The patient has a 20% co-pay after a $1000deductible, of which $500 has been met. How much will the patient owe? This is a participating physician and the contracted amount for this visit is $153.35. Since the deductible has not been met, the contracted amount will be applied toward the deductible and will be paid by the patient. 4 out of 4 points 4 out of 4 points
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Medicare is offered to those that are age 65 or older, and to certain individuals under age 65 that have disabilities. Association Group – This is offered by a different type of group other than an employer, like a credit card company offering insurance benefits to its cardholders. A triple option plan is usually operated by a single insurance plan or a joint venture among two or more insurance payers. A triple option plan allows an insurer to administer three different healthcare plans so that members may select 4 out of 4 points 4 out of 4 points
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The spenddown program under Medicaid is for people that earn too high an income or have too many assets to qualify for regular Medicaid. A spenddown is similar to a deductible. Self-Funded ERISA – The group contracts with the insurance company or third- party administrator to handle the paperwork. This is available to large groups, which pays for the operation of the insurance plan itself and the costs for administration. 4 out of 4 points 4 out of 4 points 4 out of 4 points
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Although Medicaid plans are overseen by CMS, the individual states have the option to decide rates, co-pays for certain populations, and if co-pays and deductibles will be required. Not all states offer HMO plans. When enrolling in the Medicare Advantage plans the patient is a member of the plan underwriting the policy and the claim is sent to that insurance company, not to Medicare. 4 out of 4 points 0 out of 4 points 4 out of 4 points
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A gatekeeper or PCP is provided to manage the patient’s healthcare needs. Medical credentialing is used by various organizations and insurance companies to ensure that their healthcare providers meet all of the necessary requirements and are appropriately qualified. Physicians must have the necessary credentials and go through the process to participate with an insurance company. For Medicare, credentialing is required to receive reimbursement. Credentialing allows a physician to become affiliated with insurance companies to be able to accept third party reimbursement. 4 out of 4 points 4 out of 4 points
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Response Feedback: Billing the patient for services could be problematic if the patient was told the provider was in-network and writing-off the balance can create issues with providing free care but these could be done. It would be appropriate to verify the credentialing as the claim could have been processed incorrectly. It is NOT appropriate to bill services to a provider that did not provide the care to the patient. MCOs include Exclusive Provider Organizations (EPOs); Health Maintenance Organizations (HMOs), which have already been discussed; Integrated Delivery Systems (IDSs), Preferred Provider Organizations (PPOs), and Triple Option Plans. 4 out of 4 points 4 out of 4 points
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When a provider is reimbursed per-member per-month and has patients that are at high risk and over utilize the system, it can result in higher costs and risk calculations. A National Provider Identifier, or NPI, is a unique 10-digit identification number required by HIPAA. 4 out of 4 points 4 out of 4 points
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Friday, August 4, 2017 6:58:25 PM EDT
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