Question

The patient is enrolled in a capitated HMO with a $10 copayment for primary care physician visits and no coinsurance requirements . After collecting $ 10 from the patient , what amount can the medical insurance specialist bill the payer for an office visit ?

Answer 1

The medical insurance specialist cannot bill the payer anything in addition to the $10 copayment collected from the patient in a capitated HMO plan because the payment rates are predetermined, regardless of the number of services provided.

Step-by-step explanation:

The question concerns a patient who is enrolled in a capitated HMO with a flat $10 copayment for primary care physician visits and has no coinsurance requirements. In a capitation model, health maintenance organizations (HMOs) pay a fixed amount per person to providers, regardless of how many or few services the patient uses.

After the medical insurance specialist collects the $10 copayment from the patient, the amount that can be billed to the payer for the office visit is effectively zero. This is because the payment to the medical provider from the HMO has already been set by the capitation agreement, and the copayment by the patient is typically used to partially offset the overall care costs, not to be billed in addition to the capitated amount.