CERTIFIED SPECIALIST BUSINESS
INTELLIGENCE HFMA 4 PRACTICE TEST 2026
QUESTION BANK AND CORRECT ANSWERS
REVIEW
◉ a percentage of the insurance payment amount that is paid by the
patient, along with the amount paid by the insurer. Answer:
coinsurance
◉ a flat amount that the patient pays at each time of service Answer:
copayment
◉ payment also includes amounts for services that are not included
in the patient's benefit design and amounts for services balance
billed by out-of-network providers. Payments typically does not
include premium sharing by the patient. Answer: Out-of-pocket
payment
◉ The amount payable out of pocket for healthcare services, which
may includes deductibles, copayments, coinsurance, amounts
payable by the patient for services that are not included in the
patient's benefit design, and amounts "balance billed" by out-of-
network providers. Health insurance premiums constitute a
,separate category of healthcare costs for patients, independent of
healthcare utilization. Answer: Cost (to the patient)
◉ The expense (direct and indirect) incurred to deliver healthcare
services to patients. Answer: Costs (to the provider)
◉ The amount payable to the provider (or reimbursable to the
patient) for services rendered. Answer: Cost (to the health
plan/insurer)
◉ The expense related to provided health benefits (premiums or
claims paid) Answer: Cost (to the employer)
◉ The dollar amount a provider sets for services rendered before
negotiating any discounts. The charge can be different from the
amount paid. Answer: Charge
◉ The total amount a provider expects to be paid by health
plans/payers and patients for healthcare services. Answer: Price
◉ An organization that negotiates or sets rates for provider services,
collects revenue through premium payments or tax dollars,
processes provider claims for service, and pays provider claims
using collected premium or tax revenues. Answer: Health
Plan/Payer
,◉ An entity, organization, or individual that furnishes a healthcare
service. Answer: Provider
◉ Occurs when a healthcare provider bills a patient for charges
(other than copayments, coinsurance or any amounts that may
remain on the patient's annual deductible) that exceed the health
plan's payment for a covered service. In-network providers are
contractually prohibited from balance billing health plan members,
but balance billing by out-of-network providers is common. Answer:
Balance Billing
◉ In healthcare, readily available information on the price of
healthcare services that, together with other information, helps
define the value of those services and enables patients and other
care purchasers to identify, compare and choose providers that offer
the desired level of value Answer: Price Transparency
◉ The quality of a healthcare service in relation to the total price
paid for the service by care purchasers. Answer: Value
◉ the flow of money between the patient, the insurer, and the
provider of healthcare services Answer: Revenue Cycle
, ◉ function between a healthcare facility or physician and an insurer
is one of the most important resource management challenges in
today's healthcare industry. Answer: Billing and Collection
◉ An older term used to describe payment by an insurer to a
healthcare facility or physician. This term is used because a
physician or healthcare facility provider render services to a patient
and then submits claims a claim to an insurer. The healthcare facility
or physician waits for processing of that claim by the insurer, and
ultimately recieves payment, a determination of payment or a denial
by the insurer. Today it is more common to use the term payment.
Answer: Reimbursement
◉ The price set by a healthcare facility or physician for their services
is referred to as Answer: Charges or Billed Charges
◉ The charges by a healthcare facility or physician represent the
retail price and are usually compiled in a price listing known as
Answer: Chargemaster
◉ a charge-based payment mechanism in which a provider is paid
either list price (full charges) or a percentage of charges (full
charges less a discount) for the specific services rendered. Answer:
Fee-for-service
INTELLIGENCE HFMA 4 PRACTICE TEST 2026
QUESTION BANK AND CORRECT ANSWERS
REVIEW
◉ a percentage of the insurance payment amount that is paid by the
patient, along with the amount paid by the insurer. Answer:
coinsurance
◉ a flat amount that the patient pays at each time of service Answer:
copayment
◉ payment also includes amounts for services that are not included
in the patient's benefit design and amounts for services balance
billed by out-of-network providers. Payments typically does not
include premium sharing by the patient. Answer: Out-of-pocket
payment
◉ The amount payable out of pocket for healthcare services, which
may includes deductibles, copayments, coinsurance, amounts
payable by the patient for services that are not included in the
patient's benefit design, and amounts "balance billed" by out-of-
network providers. Health insurance premiums constitute a
,separate category of healthcare costs for patients, independent of
healthcare utilization. Answer: Cost (to the patient)
◉ The expense (direct and indirect) incurred to deliver healthcare
services to patients. Answer: Costs (to the provider)
◉ The amount payable to the provider (or reimbursable to the
patient) for services rendered. Answer: Cost (to the health
plan/insurer)
◉ The expense related to provided health benefits (premiums or
claims paid) Answer: Cost (to the employer)
◉ The dollar amount a provider sets for services rendered before
negotiating any discounts. The charge can be different from the
amount paid. Answer: Charge
◉ The total amount a provider expects to be paid by health
plans/payers and patients for healthcare services. Answer: Price
◉ An organization that negotiates or sets rates for provider services,
collects revenue through premium payments or tax dollars,
processes provider claims for service, and pays provider claims
using collected premium or tax revenues. Answer: Health
Plan/Payer
,◉ An entity, organization, or individual that furnishes a healthcare
service. Answer: Provider
◉ Occurs when a healthcare provider bills a patient for charges
(other than copayments, coinsurance or any amounts that may
remain on the patient's annual deductible) that exceed the health
plan's payment for a covered service. In-network providers are
contractually prohibited from balance billing health plan members,
but balance billing by out-of-network providers is common. Answer:
Balance Billing
◉ In healthcare, readily available information on the price of
healthcare services that, together with other information, helps
define the value of those services and enables patients and other
care purchasers to identify, compare and choose providers that offer
the desired level of value Answer: Price Transparency
◉ The quality of a healthcare service in relation to the total price
paid for the service by care purchasers. Answer: Value
◉ the flow of money between the patient, the insurer, and the
provider of healthcare services Answer: Revenue Cycle
, ◉ function between a healthcare facility or physician and an insurer
is one of the most important resource management challenges in
today's healthcare industry. Answer: Billing and Collection
◉ An older term used to describe payment by an insurer to a
healthcare facility or physician. This term is used because a
physician or healthcare facility provider render services to a patient
and then submits claims a claim to an insurer. The healthcare facility
or physician waits for processing of that claim by the insurer, and
ultimately recieves payment, a determination of payment or a denial
by the insurer. Today it is more common to use the term payment.
Answer: Reimbursement
◉ The price set by a healthcare facility or physician for their services
is referred to as Answer: Charges or Billed Charges
◉ The charges by a healthcare facility or physician represent the
retail price and are usually compiled in a price listing known as
Answer: Chargemaster
◉ a charge-based payment mechanism in which a provider is paid
either list price (full charges) or a percentage of charges (full
charges less a discount) for the specific services rendered. Answer:
Fee-for-service
