CSPR HFMA CORRECT ACTUAL QUESTIONS AND
ANSWERS SURE A+
✔✔Which options are a focus of the HIPAA Title II series of laws? -✔✔-Health care
access, portability, and renewability
-To maintain the efficiency and effectiveness of the electronic transmission of health
information.
-Health care claim professional (837P), health care claim dental (837D), and health care
claim payment/advice (835)
✔✔What was the expectation of the 2010 Patient Protection and Affordable Care Act
(PPACA)? -✔✔To bring coverage to millions of Americans who could not or would not
purchase health insurance
✔✔ Steps used to control costs of managed care include: -✔✔Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
✔✔DRG is used to classify -✔✔Inpatient admissions for the purpose of reimbursing
hospitals for each case in a given category w/a negotiated fixed fee, regardless of the
actual costs incurred
✔✔Identify the various types of private health plan coverage -✔✔HMO
Conventional
PPO and POS
HDHP/SO plans - high-deductible health plans with a savings option; Private - Include
higher patient out-of-pocket expenditures for treatments that can serve to reduce
utilization/costs.
✔✔Managed care organizations (MCO) exist primarily in four forms: -✔✔Health
Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
, Exclusive Provider Organizations (EPO)
✔✔Identify the various types of government‐sponsored health coverage: -✔✔Medicare -
Government; Beneficiaries enrolled in such plans, but, participation in these
plans is voluntary.
Medicaid
Medicaid Managed Care - Medicaid beneficiaries are required to select and enroll in a
managed care plan.
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
✔✔Identify some key drivers of increasing healthcare costs -✔✔Demographics
Chronic Conditions
Provider payment systems - Provider payment systems that are designed to reward
volume rather than quality, outcomes, and prevention
Consumer Perceptions
Health Plan pressure
Physician Relationships
Supply Chain
✔✔Health Maintenance Organizations (HMO) -✔✔Referrals
PCP
Patients must use an in-network provider for their services to be covered.
Reimbursement - majority of services offered are reimbursed through capitation
payments (PMPM)
✔✔Medicare is composed of four parts: -✔✔Part A - provides inpatient/hospital,
hospice, and skilled nursing coverage
Part B - provides outpatient/medical coverage
Part C - an alternative way to receive your Medicare benefits (known as Medicare
Advantage)
Part D - prescription drug coverage
✔✔HMO Act of 1973 -✔✔The HMO Act of 1973 gave federally qualified HMOs the right
to mandate that employers offer their product to their employees under certain
conditions. Mandating an employer meant that employers who had 25 or more
employees and were for‐profit companies were required to make a dual choice available
to their employees.
✔✔Which of the following statements regarding employer-based health insurance in the
United States is true? -✔✔The real advent of employer-based insurance came through
Blue Cross, which was started by hospital associations during the Depression.
✔✔The Health Maintenance Organization (HMO) Act of 1973 gave qualified HMOs the
right to "mandate" an employer under certain conditions, meaning employers: -
✔✔Would have to offer HMO plans along side traditional fee-for-service medical plans.
ANSWERS SURE A+
✔✔Which options are a focus of the HIPAA Title II series of laws? -✔✔-Health care
access, portability, and renewability
-To maintain the efficiency and effectiveness of the electronic transmission of health
information.
-Health care claim professional (837P), health care claim dental (837D), and health care
claim payment/advice (835)
✔✔What was the expectation of the 2010 Patient Protection and Affordable Care Act
(PPACA)? -✔✔To bring coverage to millions of Americans who could not or would not
purchase health insurance
✔✔ Steps used to control costs of managed care include: -✔✔Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
✔✔DRG is used to classify -✔✔Inpatient admissions for the purpose of reimbursing
hospitals for each case in a given category w/a negotiated fixed fee, regardless of the
actual costs incurred
✔✔Identify the various types of private health plan coverage -✔✔HMO
Conventional
PPO and POS
HDHP/SO plans - high-deductible health plans with a savings option; Private - Include
higher patient out-of-pocket expenditures for treatments that can serve to reduce
utilization/costs.
✔✔Managed care organizations (MCO) exist primarily in four forms: -✔✔Health
Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
, Exclusive Provider Organizations (EPO)
✔✔Identify the various types of government‐sponsored health coverage: -✔✔Medicare -
Government; Beneficiaries enrolled in such plans, but, participation in these
plans is voluntary.
Medicaid
Medicaid Managed Care - Medicaid beneficiaries are required to select and enroll in a
managed care plan.
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
✔✔Identify some key drivers of increasing healthcare costs -✔✔Demographics
Chronic Conditions
Provider payment systems - Provider payment systems that are designed to reward
volume rather than quality, outcomes, and prevention
Consumer Perceptions
Health Plan pressure
Physician Relationships
Supply Chain
✔✔Health Maintenance Organizations (HMO) -✔✔Referrals
PCP
Patients must use an in-network provider for their services to be covered.
Reimbursement - majority of services offered are reimbursed through capitation
payments (PMPM)
✔✔Medicare is composed of four parts: -✔✔Part A - provides inpatient/hospital,
hospice, and skilled nursing coverage
Part B - provides outpatient/medical coverage
Part C - an alternative way to receive your Medicare benefits (known as Medicare
Advantage)
Part D - prescription drug coverage
✔✔HMO Act of 1973 -✔✔The HMO Act of 1973 gave federally qualified HMOs the right
to mandate that employers offer their product to their employees under certain
conditions. Mandating an employer meant that employers who had 25 or more
employees and were for‐profit companies were required to make a dual choice available
to their employees.
✔✔Which of the following statements regarding employer-based health insurance in the
United States is true? -✔✔The real advent of employer-based insurance came through
Blue Cross, which was started by hospital associations during the Depression.
✔✔The Health Maintenance Organization (HMO) Act of 1973 gave qualified HMOs the
right to "mandate" an employer under certain conditions, meaning employers: -
✔✔Would have to offer HMO plans along side traditional fee-for-service medical plans.
