Case of the Three Boys with Three Plans

Matt, Marvin and Michael are excited to see Dr. Smith, that great new Dermatologist across town.  All three brothers suffer with acne and they are being seen today for new patient exams and medication.

1.      Matt has a PPO plan that pays 80/20 (in net) &  60/40 (out of net).  Dr. Smith is not in his network.

2.     Marvin has an HMO plan that pays 100% after a $5.00 copay. Dr. Smith is in his network.

3.     Michael has an EPO that pays 100% (in net) &  0% (out of net).  Dr. Smith is not in his network.

Note:  None of the plans have a plan deductible and no referrals were obtained in advance.


Answer the Following Questions


Which plan(s) require a referral in advance of the visit? Indicate all that apply.

A

All of the plans

C

Matt's Plan

B

Marvin's Plan

D

Michael's Plan

What are the patients expected to pay upfront?

MATT'S PPO PLAN

A

100% of the claim

D

40% of the claim

B

80% of the claim

E

Zero

C

60% of the claim

F

$5.00

MARVIN'S HMO PLAN

A

100% of the claim

D

40% of the claim

B

80% of the claim

E

Zero

C

60% of the claim

F

$5.00

MICHAEL'S EPO PLAN

A

100% of the claim

 D

40% of the claim

B

80% of the claim

E

Zero

C

60% of the claim

F

$5.00

What are the health carriers expected to pay toward each visit?

MATT'S PPO PLAN

A

100% after a copay

D

60 percent

B

Zero – claim denied

E

40 percent

C

80 percent

MARVIN'S HMO PLAN

A

100% after a copay

D

60 percent

B

Zero – claim denied

E

40 percent

C

80 percent

MICHAEL'S EPO PLAN

A

100% after a copay

D

60 percent

B

Zero – claim denied

E

40 percent

C

80 percent

How will any remaining balances be handled?

MATT'S PPO PLAN

A

Write off

B

Patient responsibility

MARVIN'S HMO PLAN

A

Write off

B

Patient responsibility

MICHAEL'S EPO PLAN

A

Write off

B

Patient responsibility

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