Chapter 5 CPMA Exam: Contract-based
Commercial Insurance Plans. Exam
Questions With Verified Answers.
Most common commercial insurance plans are - answercontract based
That is, benefits arise primarily under a contract between the insurance company and the
subscriber/patient
Where the healthc...
Most common commercial insurance plans are - answer✔contract based
That is, benefits arise primarily under a contract between the insurance company and the
subscriber/patient
Where the healthcare provider is in network, - answer✔the provider agrees to abide by certain
rules in a separate contract..
The auditor must review the contract to determine the rules the provider is bound to follow
For commercial insurance plans, determine if the providers is obligate to - answer✔conform to
the insurance company's published medical policies
Cigna requires par and nonpars to conform if want reimbursment
If a commercial insurance plan requires the provider to conform to insurance company's
published medical policies, determinis non-conformance - answer✔entitles the payer to recoup
the money, or is the only sanction potential termination of the provider network status?
Is the provider offered a chance at implementing corrective action?
How these questions are answered will significantly affect the audit result, in terms of whether
an auditor can declare error or can simply declare potential risk.
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