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
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
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
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
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
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
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
Friday, August 4, 2017 6:58:25 PM EDT
