Certified Medical Assistant (CMA AAMA)Administrative: Billing, Coding and SchedulingMedium
A medical assistant is reconciling payments for the day. A patient's Explanation of Benefits (EOB) shows a 'coinsurance' amount of $20.00. The patient's plan has an 80/20 coinsurance. The allowed amount for the service was $100.00, and the deductible has already been met. How much did the insurance company pay?
- A$80.00
- B$100.00
- C$0.00
- D$20.00
Show answer & explanationAnswer & explanation
Correct answer: A. $80.00
With an 80/20 coinsurance, the insurance company pays 80% of the allowed amount after the deductible is met. In this case, 80% of $100.00 is $80.00. The remaining 20% ($20.00) is the patient's responsibility.
Why the other options are wrong
- B. This is the total allowed amount, not what the insurance paid, as the patient has coinsurance.
- C. The insurance company paid a portion of the allowed amount, so $0.00 is incorrect.
- D. This is the patient's coinsurance responsibility, not the insurance payment.
Coinsurance Calculation
The patient's share of the cost of a covered health care service, calculated as a percentage of the allowed amount after the deductible has been met.
- Calculated after the deductible is paid.
- Expressed as a percentage (e.g., 80/20).
- Patient pays their percentage, insurance pays the rest.
- Based on the 'allowed amount,' not the billed amount.
Memory trick: Coinsurance: 'C' for 'Cut' of the bill, 'I' for 'Insurance's share'.