Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby

Exercise 8

Calculating Insurance Math
Calculate the payment(s) billed in each of the following situations:
A. The patient's health plan has a $100 annual deductible. At the first visit of the year, the charges are $95. What does the patient owe?
B. The patient's coinsurance percentage is stated as 75-25 in the insurance policy. The deductible for the year has been met. If the visit charges are $1,000, what payment should the medical insurance specialist expect from the payer? What amount will the patient be billed?
C. The patient's coinsurance percentage is stated as 80-20 in the insurance policy. The deductible for the year has been met. If the visit charges are $420, what payment should the medical insurance specialist expect from the payer? What amount will the patient be billed?
D. The patient is enrolled in a capitated HMO with a $10 copayment for primary care physician visits and no coinsurance requirements. After collecting $10 from the patient, what amount can the medical insurance specialist bill the payer for an office visit?
E. The patient has a policy that requires a $20 copayment for an in-network visit due at the time of service. The policy also requires 30 percent coinsurance from the patient. Today's visit charges total $785. After subtracting the copayment collected from the patient, the medical insurance specialist expects a payment of what amount from the payer? What amount will the patient be billed?
F. A patient's total surgery charges are $1,278. The patient must pay the annual deductible of $1,000, and the policy states a 80-20 coinsurance. What does the patient owe?
G. A patient has a high-deductible consumer-driven health plan. The annual deductible is $2,500, of which $300 has been paid. After a surgical procedure costing $1,890, what does the patient owe? Can any amount be collected from a payer? Why?
H. A patient with a high-deductible consumer-driven health plan has met half of the $1,000 annual deductible before requiring surgery to repair a broken ankle while visiting a neighboring state. The out-of-network physician's bill is $4,500. The PPO that takes effect after the deductible has been met is an 80-20 in-network plan and a 60-40 out-of-network plan. How much does the patient owe? How much should the PPO be billed?