Difficulty: Medium

Average Score: 65%

All of the following apply to payment of claims on a managed care plan EXCEPT

Rationale

The covered person normally receives reimbursement for the service direct from the Insurer.

In managed care plans, the payment process typically involves direct payment to the healthcare provider rather than reimbursement to the covered person, as these plans often have networks of providers who are paid directly for their services.

A (the covered person normally receives reimbursement for the service direct from the insurer.) CORRECT

Managed care plans generally operate on a system where the insurer pays the healthcare provider directly rather than reimbursing the covered person. This structure is designed to streamline the payment process and reduce the administrative burden on individuals seeking care.

B (it is generally not required that covered persons file claim forms.) YOUR ANSWER

In many managed care plans, especially those using a network of providers, covered persons do not need to file claim forms for services rendered, as the provider handles the billing directly with the insurer. This simplifies the process for the patient, aligning with the managed care model.

C (a covered person may be responsible for an increased co-payment if they visit a non-network provider.) YOUR ANSWER

This statement is accurate, as managed care plans often impose higher out-of-pocket costs, such as co-payments, for services rendered by non-network providers to encourage the use of in-network services. This cost-sharing mechanism helps manage overall healthcare expenses.

D (reimbursement may be denied if a covered person visits a specialist without a required referral.) YOUR ANSWER

This statement is also true, as many managed care plans require referrals to specialists from a primary care provider. If a covered person sees a specialist without this referral, the insurer may deny reimbursement for the service, enforcing the plan’s referral policy.

Conclusion

In summary, the payment structure of managed care plans typically favors direct payment to providers rather than reimbursement to covered persons, making option A the only incorrect statement among the choices. The other options accurately describe aspects of managed care, such as claims processing, co-payments, and referral requirements, which are integral to the operation of these plans.

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