12. tf: payers usually do not use a consistent payment methodology or amounts for different products such as…

12. tf: payers usually do not use a consistent payment methodology or amounts for different products such as hmos, ppos, medicare advantage plans, and pos plans.\n13. tf: a participating provider is permitted to balance bill a member for any copayments, coinsurance, or deductibles that are applicable to a claim payment.\n14. tf: a participating provider is permitted to balance bill a member for any amount above the amount paid under the payers fee schedule.\n15. which of the following is rarely if ever involved in payment for prescription drugs? a. average wholesale price b. copay c. coinsurance d. rebates e. capitation f. reference pricing\n16. tf an ids may not operate primarily as a vehicle for negotiating terms with private payers.\n17. tf the gpww requires the participation of a hospital and the formation of a group practice.

12. tf: payers usually do not use a consistent payment methodology or amounts for different products such as hmos, ppos, medicare advantage plans, and pos plans.\n13. tf: a participating provider is permitted to balance bill a member for any copayments, coinsurance, or deductibles that are applicable to a claim payment.\n14. tf: a participating provider is permitted to balance bill a member for any amount above the amount paid under the payers fee schedule.\n15. which of the following is rarely if ever involved in payment for prescription drugs? a. average wholesale price b. copay c. coinsurance d. rebates e. capitation f. reference pricing\n16. tf an ids may not operate primarily as a vehicle for negotiating terms with private payers.\n17. tf the gpww requires the participation of a hospital and the formation of a group practice.

Answer

Brief Explanations:

  1. Payers often have different payment methods for various health - care plans like HMOs, PPOs etc. due to their different structures and agreements. So the statement is True.
  2. A participating provider is usually not allowed to balance bill a member for copayments, coinsurance or deductibles as per the agreement with the payer. So the statement is False.
  3. Participating providers are generally prohibited from balance - billing members for amounts above the payer's fee schedule. So the statement is False.
  4. Capitation is a payment model for providers based on the number of patients they serve, and is rarely involved in prescription drug payment. The other terms are more directly related to drug payment. So the answer is e. Capitation.
  5. An IDS (Integrated Delivery System) can operate as a vehicle for negotiating with private payers. So the statement is False.
  6. The GPWW (Group Practice Without Walls) does not necessarily require the participation of a hospital and the formation of a group practice in the traditional sense. So the statement is False.

Answer:

  1. True
  2. False
  3. False
  4. e. Capitation
  5. False
  6. False