Chapter 2_workbook exercises(1)

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Principles of Healthcare Reimbursement and Revenue Cycle Management Eighth Edition Student Workbook Chapter2 Health Insurance Copyright ©2024 by the American Health Information Management Association. All rights reserved.

Principles of Healthcare Reimbursement and Revenue Cycle Management Student Workbook Chapter 2 INSTRUCTIONS: Complete the following exercises 1 through 3 1. Summary of Benefits and Coverage(10 points) Use figure 2.2from the textbook to identify the cost-sharing components. Complete the accompanying table. Question Answer What is the cost-sharing for a generic drug, network provider? $10 copay/ prescription (retail and mail order) What is the cost-sharing for a tier 2 drug purchased at an out-of- network pharmacy? 40% coinsurance What is the cost-sharing for a specialty drug, network provider? 50% coinsurance What is the cost-sharing for a network immunization visit? No charge What is the cost-sharing for a network primary care visit $35 copay/office visit and 20% coinsurance for outpatient services, deductible does not apply What is the cost-sharing for anetwork specialist visit? $50 copay/ visit What is the cost-sharing for an out-of-network primary care visit? 40% coinsurance What is the cost-sharing for x-rays provided by a network provider? $10 copay/ test What is the cost-sharing for outpatient surgery provided at a network facility? $100/day copay for facility fees, 20% coinsurance for physician/surgeon fees, 50% coinsurance for anesthesia What is the cost-sharing amount for the surgeon fees for outpatient surgery provided at an out-of-network facility? 40% coinsurance 2. Cost-Sharing Expense(4 points) Copyright ©2024 by the American Health Information Management Association. All rights reserved.

Principles of Healthcare Reimbursement and Revenue Cycle Management Student Workbook Chapter 2 Calculate the cost-sharing amount for four scenarios. The total reimbursement amount that will be paid to the providers is listed. Using the cost-sharing parameters as outlined in figure 2.1 , cost sharing provision section of a sample Summary of Benefits and Coverage, determine how much of the total reimbursement will be paid by the beneficiary. [Note: All deductibles have been satisfied.] EXAMPLE: Primary care visit, network provider Encounter with Dr. King for sinus infection. Visit DOS: 01/31/20XX Total reimbursement to Dr. King = $252.64 Cost-sharing amount is $35. The beneficiary pays a copayment amount of $35 for primary care visits to treat an injury when the provider is a network provider. a. Outpatient hospital surgery Admission to Community Hospital (network) Admission DOS: 6/1/20XX ‒ 6/1/20XX Total reimbursement to Community Hospital:$5,325 Cost-sharing amount is $100 b. Outpatient hospital surgery—surgeon fees Dr. Meishkou (network) Admission DOS: 6/1/20XX ‒ 6/1/20XX Total reimbursement to Dr. Meishkou: $1,225 Cost-sharing amount is $245 c. Cardiologist visit, out-of-network Encounter at Dr. Edwards’ office Visit DOS: 07/06/20XX Total reimbursement to Dr. Edwards: $450 Cost-sharing amount is $180 d. Pharmacy prescription, preferred brand drug, network provider Pharmacy at U-Shop Date prescription filled: 10/04/20XX Total reimbursement for U-Shop:$55.00 Cost-sharing amount is $30 Copyright ©2024 by the American Health Information Management Association. All rights reserved.

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Principles of Healthcare Reimbursement and Revenue Cycle Management Student Workbook Chapter 2 3. Choosing MCO Service Management Tools(3 points) MCOs use service management tools to control costs. Following are three healthcare service scenarios. For each scenario, choose which service management tool(s) an MCO would utilize prior to healthcare service delivery. Review table 2.2 for a refresher on service management tools. Scenario A A patient visits a PCP for ongoing heel pain, which is diagnosed as plantar fasciitis. The patient requests to see a podiatrist for further treatment. Which service management tool(s) would be utilized by the MCO before the patient is approved for the podiatrist visit? Gatekeeper role of PCP Scenario B A patient’s orthopedic surgeon would like to perform spinal fusion for ongoing lumbar pain due to herniated discs. The MCO wants to ensure that the treatment will be effective. Which service management tool(s) would the MCO use to ensure that the requested treatment will be effective? Gatekeeper role of PCP, utilization management and utilization review Scenario C A patient was thrown from a horse during riding practice. The patient experienced a severe head injury andrequired the services of multiple healthcare providers at various locations throughout the state. Which service management tool(s) would be utilized by the MCO for this scenario to ensure that the patient receives cost-effective and efficient care? Second and third opinions, case management, and utilization management and utilization review Copyright ©2024 by the American Health Information Management Association. All rights reserved.

Chapter 2_workbook exercises(1)

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