Practice Quiz

Health and Life Insurance

Category - HMOs

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Bill is out of town on a skiing trip in a small village with limited communication to the surrounding areas. Coming down a black diamond run, Bill misses the final turn and breaks his leg as he tumbles to the bottom of the hill. At the emergency room, Bill notes in his paperwork that he is an HMO member. What will the HMO most likely do when Bill notifies them of the accident?
  1. Reimburse Bill the set amount they would have paid someone in network
  2. Pay the claim even though Bill is outside of his network
  3. Deny payment because it was not pre-authorized
  4. Pay the claim if an affiliate and charge Bill the overage amount.
Explanation
Answer: B - The HMO will most likely pay the claim even though Bill is outside of his network. As part of the HMO policy, member’s needs are covered in emergency situations. The member will need to contact their primary care provider as soon as it is possible to do so. HMOs have a general 24 hour access rule where members can contact the HMO for referrals and authorizations 24 hours a day, 7 days a week. Those on the nursing and medical staff, along with the primary care physicians in the HMO are required to be willing to respond outside of regular business hours.
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