Network Fundamentals Flashcards
7 cards from real CCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Network Fundamentals flashcards as text
A patient's plan uses a tiered network design. Which tier typically results in the lowest out-of-pocket cost for the patient?
Answer: Tier 1 (preferred in-network)
In tiered networks, Tier 1 (preferred in-network) providers offer the lowest cost-sharing because they have met quality and cost-efficiency benchmarks set by the plan.
What does 'balance billing' refer to in network-related billing?
Answer: A provider billing a patient for the difference between their charge and the payer's allowed amount
Balance billing occurs when an out-of-network provider bills the patient for the amount remaining after the insurance payment, beyond the plan's allowed amount.
Which act prohibits surprise billing for emergency services from out-of-network providers at in-network facilities?
Answer: The No Surprises Act
The No Surprises Act (effective January 1, 2022) protects patients from unexpected bills for emergency care and certain non-emergency services from out-of-network providers at in-network facilities.
A provider's contract with a health plan specifies a fee schedule based on a percentage of Medicare rates. If the contracted rate is 120% of Medicare, and the Medicare allowable is $100, what does the provider receive?
Answer: $120
120% of the $100 Medicare allowable equals $120, which is the contracted reimbursement rate the health plan will pay the provider.
In managed care, 'network leakage' refers to:
Answer: Members using out-of-network providers instead of in-network ones
Network leakage describes the pattern of plan members seeking care outside the network, which increases costs and reduces the plan's ability to manage care effectively.
A health plan removes a provider from its network. What is this action called?
Answer: De-credentialing
De-credentialing is the formal process of removing a provider from a health plan's network, often due to quality concerns, license issues, or failure to meet standards.
An 'any willing provider' law, if enacted in a state, generally requires that:
Answer: Health plans must accept any licensed provider who agrees to the plan's terms
Any willing provider laws require health plans to include in their networks any licensed provider who is willing to meet the plan's participation terms and conditions.