Chapter 5 CPMA Exam: Contract-based
Commercial Insurance Plans Questions
and Answers
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 ...
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.
Where the provider is not contracted with a particular payer, consider the provider -
Answer✔✔-has no legal duty to conform his or her reporting or documentation to the
mandates of the payer's medical policies.
Although this might prevent an auditor from declaring an error, it does not prevent an auditor
from identifying potential risk and suggesting change that would assist the provider in avoiding
an issue with that carrier.
Insurance contracts are not always available to the - Answer✔✔-auditor (I have yet to see one)
State regulated Commercial insurance plans - Answer✔✔-are mostly associated with first party
medical claims in an auto insurance case (where the state law requires or provides for such
coverage)
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