CCS Network Fundamentals 3

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?

Accepted Answer

Tier 1 (preferred in-network)

Answer

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?

Accepted Answer

A provider billing a patient for the difference between their charge and the payer's allowed amount

Answer

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?

Accepted Answer

The No Surprises Act

Answer

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?

Accepted Answer

$120

Answer

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:

Accepted Answer

Members using out-of-network providers instead of in-network ones

Answer

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.

(CCS) Certified Coding Specialist Practice Test

(CCS) Certified Coding Specialist Practice Test

CCS Network Fundamentals 3