CHFP MODULE 1 CERTIFICATION TEST EXAM QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTIONS VERIFIED
is a pre-determined amount that the patient pays before the insurer begins to pay for services
deductible
a percentage of the insurance payment amount that is paid by the patient, along with the amount
paid by the insurer.
coinsurance
a flat amount that the patient pays at each time of service
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.
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.
Cost (to the patient)
,The expense (direct and indirect) incurred to deliver healthcare services to patients.
Costs (to the provider)
The amount payable to the provider (or reimbursable to the patient) for services rendered.
Cost (to the health plan/insurer)
The expense related to provided health benefits (premiums or claims paid)
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.
Charge
The total amount a provider expects to be paid by health plans/payers and patients for healthcare
services.
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.
Health Plan/Payer
An entity, organization, or individual that furnishes a healthcare service.
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.
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
Price Transparency
The quality of a healthcare service in relation to the total price paid for the service by care purchasers.
Value
the flow of money between the patient, the insurer, and the provider of healthcare services
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.
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.
Reimbursement
The price set by a healthcare facility or physician for their services is referred to as
, 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
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.
Fee-for-service
What does fee for service payment provides?
more units of service in order to receive more payments.
Why do Healthcare Facilities set Retail prices significantly above rates actually paid by commercial
insurers or the government?
1. Access to Contracted Payment Rates.
-Rare not all insurers participate in provider networks that give them access to contracted payment
rates. Some auto insurers, liability insurers or companies providing travel insurance to visitors from
abroad still pay a provider's full charges.
2. Percent-of-Charge Contracts
-In markets with little competition, percent-of-charge contracts are still common. The higher the price,
the higher the percent-of-charge payment, unless the contract limits a provider's annual price increases.
3. Outlier Provisions
-Some insurance contacts contain an outlier provision that entitles providers to an additional payment (a
lump-sum payment or a percentage of actual charges above a threshold) for particularly sick and high-
cost patients.
ANSWERS WITH COMPLETE SOLUTIONS VERIFIED
is a pre-determined amount that the patient pays before the insurer begins to pay for services
deductible
a percentage of the insurance payment amount that is paid by the patient, along with the amount
paid by the insurer.
coinsurance
a flat amount that the patient pays at each time of service
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.
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.
Cost (to the patient)
,The expense (direct and indirect) incurred to deliver healthcare services to patients.
Costs (to the provider)
The amount payable to the provider (or reimbursable to the patient) for services rendered.
Cost (to the health plan/insurer)
The expense related to provided health benefits (premiums or claims paid)
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.
Charge
The total amount a provider expects to be paid by health plans/payers and patients for healthcare
services.
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.
Health Plan/Payer
An entity, organization, or individual that furnishes a healthcare service.
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.
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
Price Transparency
The quality of a healthcare service in relation to the total price paid for the service by care purchasers.
Value
the flow of money between the patient, the insurer, and the provider of healthcare services
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.
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.
Reimbursement
The price set by a healthcare facility or physician for their services is referred to as
, 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
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.
Fee-for-service
What does fee for service payment provides?
more units of service in order to receive more payments.
Why do Healthcare Facilities set Retail prices significantly above rates actually paid by commercial
insurers or the government?
1. Access to Contracted Payment Rates.
-Rare not all insurers participate in provider networks that give them access to contracted payment
rates. Some auto insurers, liability insurers or companies providing travel insurance to visitors from
abroad still pay a provider's full charges.
2. Percent-of-Charge Contracts
-In markets with little competition, percent-of-charge contracts are still common. The higher the price,
the higher the percent-of-charge payment, unless the contract limits a provider's annual price increases.
3. Outlier Provisions
-Some insurance contacts contain an outlier provision that entitles providers to an additional payment (a
lump-sum payment or a percentage of actual charges above a threshold) for particularly sick and high-
cost patients.
