CCS Network Fundamentals 3 — Questions and Answers
Question 1: A patient's plan uses a tiered network design. Which tier typically results in the lowest out-of-pocket cost for the patient?
- Tier 3 (out-of-network)
- Tier 2 (preferred out-of-network)
- Tier 1 (preferred in-network) (Correct answer)
- All tiers have equal cost-sharing
Correct 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.
Question 2: What does 'balance billing' refer to in network-related billing?
- The insurer's practice of adjusting claims after audit
- A provider billing a patient for the difference between their charge and the payer's allowed amount (Correct answer)
- The process of splitting costs between primary and secondary insurers
- Retroactive adjustments made by the plan to provider payments
Correct 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.
Question 3: Which act prohibits surprise billing for emergency services from out-of-network providers at in-network facilities?
- HIPAA
- The No Surprises Act (Correct answer)
- ERISA
- The Stark Law
Correct 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.
Question 4: 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?
- $100
- $80
- $120 (Correct answer)
- $20
Correct answer: $120
120% of the $100 Medicare allowable equals $120, which is the contracted reimbursement rate the health plan will pay the provider.
Question 5: In managed care, 'network leakage' refers to:
- Unauthorized disclosure of provider contracts
- Members using out-of-network providers instead of in-network ones (Correct answer)
- Payers underpaying contracted providers
- Claims being sent to the wrong payer
Correct 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.
Question 6: A health plan removes a provider from its network. What is this action called?
- De-credentialing (Correct answer)
- Network exclusion
- Provider suspension
- Disenrollment
Correct 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.
Question 7: An 'any willing provider' law, if enacted in a state, generally requires that:
- All providers charge the same rates
- Health plans must accept any licensed provider who agrees to the plan's terms (Correct answer)
- Members must use only government-designated providers
- Providers cannot refuse Medicaid patients
Correct 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.
CCS Network Fundamentals 3
A patient's plan uses a tiered network design.
Which tier typically results in the lowest out-of-pocket cost for the patient?