HSA 4109 Exam 2 questions well
answered graded A+ passed
Allowed Amount
The maximum amount an in-network provider can charge members for a given service. This is
the negotiated rate that an insurance company has agreed upon with in-network providers
Balance Billing
prohibits in-network providers from chargin health plan enrollees the difference between
provider actual charges and the allowable rate negotiated with the insurance company
Capitation
a payment arrangement under which providers are paid a fixed amount based on the insurance
membership instead of services received. This per-member, per-month amount is paid to the
provider regardless of whether the insured member receives a service during the month. In this
way, the provider receives a capped payment and assumes financial risk if the cost of the service
exceed the monthly rate.
Charge master
a list of a hospital's charges for medical services. Typically, these charges are higher than what
an insurance company actually pays.
Diagnosis-Related Groups (DRGs)
, a bundles payment arrangement for inpatient services that is used by Medicare. Each group if
services is weighted to reflect the average cost of resources used in providing services. Because
this payment is established prior to the service being rendered, it is considered a prospective
payment, and places the provider at some financial risk.
Explanation of Benefits (EOB)
statement from an insurance company that provides information on provider service charges,
the amount the insurance company paid, the amount for which the member is responsible.
Fee-for-Service
Method of service delivery and financing where providers are paid for each service performed,
and patients have the freedom to choose the providers they see. "Fee for service" plans are also
known as "indemnity" plans.
Fee Schedule
list of maximum allowable fees that an insurance company will pay for services
Price Transparency
pricing information that is available to consumers and payers to help define the value of
healthcare services when comparing providers or facilities
Prospective payment
fixed provider payment rate that has been negotiated under contract prior to a service bein
rendered and costs incurred
answered graded A+ passed
Allowed Amount
The maximum amount an in-network provider can charge members for a given service. This is
the negotiated rate that an insurance company has agreed upon with in-network providers
Balance Billing
prohibits in-network providers from chargin health plan enrollees the difference between
provider actual charges and the allowable rate negotiated with the insurance company
Capitation
a payment arrangement under which providers are paid a fixed amount based on the insurance
membership instead of services received. This per-member, per-month amount is paid to the
provider regardless of whether the insured member receives a service during the month. In this
way, the provider receives a capped payment and assumes financial risk if the cost of the service
exceed the monthly rate.
Charge master
a list of a hospital's charges for medical services. Typically, these charges are higher than what
an insurance company actually pays.
Diagnosis-Related Groups (DRGs)
, a bundles payment arrangement for inpatient services that is used by Medicare. Each group if
services is weighted to reflect the average cost of resources used in providing services. Because
this payment is established prior to the service being rendered, it is considered a prospective
payment, and places the provider at some financial risk.
Explanation of Benefits (EOB)
statement from an insurance company that provides information on provider service charges,
the amount the insurance company paid, the amount for which the member is responsible.
Fee-for-Service
Method of service delivery and financing where providers are paid for each service performed,
and patients have the freedom to choose the providers they see. "Fee for service" plans are also
known as "indemnity" plans.
Fee Schedule
list of maximum allowable fees that an insurance company will pay for services
Price Transparency
pricing information that is available to consumers and payers to help define the value of
healthcare services when comparing providers or facilities
Prospective payment
fixed provider payment rate that has been negotiated under contract prior to a service bein
rendered and costs incurred
