Payer Types and Policies Flashcards

A 68-year-old patient covered by traditional Medicare receives medically necessary inpatient care at a skilled nursing facility (SNF) following a qualifying three-day hospital stay. Which part of Medicare is responsible for covering the SNF charges?

Answer: Medicare Part A

Medicare Part A, also known as Hospital Insurance, covers costs associated with inpatient hospital care, skilled nursing facility care, hospice, and home health care.

A 72-year-old patient has both Medicare and a state Medicaid plan. The patient receives services from a physician who accepts both types of insurance. How should the claim be processed?

Answer: The claim should be submitted to Medicare first, and Medicaid will be the secondary payer.

Federal law establishes Medicaid as the "payer of last resort." This means that all other available third-party payers, including Medicare, must be billed and pay their portion before a claim can be submitted to Medicaid.

Which of the following is a defining characteristic of most Health Maintenance Organization (HMO) plans?

Answer: It requires patients to select a Primary Care Physician (PCP) to manage their care.

A core feature of most HMO plans is the requirement for members to choose a Primary Care Physician (PCP). This PCP acts as a "gatekeeper," managing the patient's overall care and providing referrals for specialist services.

A patient with a Preferred Provider Organization (PPO) plan chooses to see a specialist who is not in the PPO network. Which of the following outcomes is most likely?

Answer: The patient will likely have a higher coinsurance or copayment and a separate, higher deductible for out-of-network services.

PPO plans offer members the flexibility to see out-of-network providers. However, this flexibility typically comes at a higher cost to the patient in the form of increased cost-sharing responsibilities (copayments, coinsurance, and deductibles) compared to using in-network providers.

A patient is treated for an acute injury that occurred at their workplace. The patient provides their commercial health insurance card at check-in. What is the correct procedure for the billing specialist?

Answer: Open a workers' compensation claim and bill that carrier directly.

When an injury or illness is work-related, the claim must be submitted to the workers' compensation insurance carrier, not the patient's personal health insurance. A separate case file should be created, and billing must be directed to the entity responsible for the workers' compensation coverage.

A primary care physician's practice has a contract with an insurance company where it receives a flat payment of $30 per month for each patient assigned to the practice, regardless of how many times the patient is seen or what services are provided. This payment model is known as:

Answer: Capitation

Capitation is a payment model where providers are paid a fixed amount per patient for a prescribed period of time (per-member-per-month), regardless of the quantity or cost of services rendered.