Question

1. The patient is insured by a PPO with 100 percent coverage after a copay of $15. The patient was seen in the office for a checkup, and the total charges were $115. What amount must the patient pay? When? What amount must the insurance plan pay? When?

2 Afaf Darcy is insured by an HMO with a $10 copay and out-of-network coinsurance on charge balances of 90-10. She needed ysical therapy after her knee replacement. Her HMO pays for eighteen physical therapy sessions in such cases at a rate of $63.50 per visit. If additional physical therapy is needed, the provider must document the reasons and submit a formal request. The therapist requested additional visits, and Ms. Darcy attended five additional physical therapy sessions. The request was denied. What amount will the insurance company pay for her physical therapy? What amount must Ms. Darcy pay?

3. Mike Moroni is covered by a member health plan with a 20 percent discount from the provider's ual fear d a 520.00 copay. The charges are $365.50. What amount will the HMO pay? What does the patient owe?

4. Lisa Perez was seen in your office twice last fall. Her deductible has been met and her coinsurance is 85-15. In October, she was seen for influenza vaccination, and her insurance company was billed $13.00 for the vaccine and $9.00 for the administration of the vaccine. Lisa's schedule of benefits for her indemnity insurance plan lists the influenza administration as being a covered service, but it does not include the actual vaccine. In December, Lisa had an office visit and had blood drawn to be sent to an outside lab; both these services are included in the schedule of benefits.

The ledger card or patient statement shows the dates and charges for services; you need to calculate each amount paid by the insurance plan and enter it on the ledger card or patient statement. Remember to keep a running balance.

5. Harold and Helen Rubright's coverage is with a consumer-driven PPO with a high deductible of $1,000. The patient must pay a $25 copay for office visits. Previously, Mr. Rubright was seen in the office for a minor surgical procedure with charges totaling $1,000. The PPO was billed to maintain a record of the deductible; Mr. Rubright paid $1,000 on 5/3. These entries are shown on the ledger card/patient statement. On 6/21 Mrs. Rubright was seen for an office visit. Charges were $65, Make the next two entries on the ledger card/patient statement. Mr. Rubright was seen for an office visit on 10/5. Charges were $115. Make the necessary entries in the ledger card/patient statement.

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Answer 1

(One Question Per Post) 

(Only answer question 1)

The patient must pay $115 at the time of visit for a checkup.

An insurance plan allows $100 for a health care checkup and you have paid your deductible, your coinsurance payment of 20% (or whatever percent applies to your insurance plan) would be $20. Your insurance plan will pay the remaining amount of $80 due for your visit.