CSPR HFMA EXAMINATION QUESTIONS AND
ANSWERS SURE A+
✔✔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.
✔✔Which of the following is an anticipated change in the relationships between
consumers and providers? -✔✔Providers will face many new service demands and
consumers will have virtually unfettered access to those services
✔✔What transition began as a result of the March 2010 healthcare reform legislation? -
✔✔A transition toward new models of health care delivery with corresponding changes
system financing and provider reimbursement.
✔✔Which statement is false concerning ABNs? -✔✔ABN began establishing new
requirements for managed care plans participating in the Medicare program.
✔✔Which Statement is TRUE concerning ABNs? -✔✔-ABNs are not required for
services that are never covered by Medicare.
-An ABN form notifies the patient before he or she receives the service that it may not
be
,covered by Medicare and that he or she will need to pay out of pocket.
-Although ABNs can have significant financial implications for the physician, they also
serve an important fraud and abuse compliance function.
✔✔What is the overall function of Medicaid? -✔✔The pay for medical assistance for
certain individuals and low-income families
✔✔Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: -✔✔Total
Medical Expenses divided by Total Premiums
✔✔Provider service organizations (PSOs) function like health maintenance
organizations (HMOs) in all of the following ways, EXCEPT: -✔✔Ties to the healthcare
delivery industry rather than the insurance industry
✔✔Provider service organizations (PSOs) function like health maintenance
organizations (HMOs) in all of the following ways: -✔✔-Risk pooling
-Capitalization
-Network management
✔✔Which of the following is a service provided by a well-managed third-party
administrator (TPA)? -✔✔-Administrative
-Utilization review (UR)
-Claims processing
✔✔What is tiering? -✔✔The ranking or classifying of one or more of the provider
delivery system components
✔✔Which option is a practice used to control costs of managed care? -✔✔-Making
advance payment to providers for all services needed to care for a member
-Combining services provided and bundling the associated charges
-Agreement between the payer and provider on reasonable payment for each service.
✔✔Which option is a risk involved in per diem payments? -✔✔-The risk to the insurance
company or health plan
-The risk to the hospital
-The risk when embracing per diem payments in complex case
✔✔Diagnosis-related group (DRG) is: -✔✔A payment category
✔✔How is the term carve-out used when discussing managed care? -✔✔To refer to
specific benefits or services
✔✔What is the term Coordination of Benefits (COB)? -✔✔A term used to describe how
payment is coordinated for patients who have coverage through two insurance policies
, ✔✔Which three components are used to determine the total RVU value for a service? -
✔✔-Malpractice expense
-Lowest market price for services used
-Medicare discounts
✔✔A fixed payment amount based upon the number of members assigned to a
provider, and does not vary based upon the number of services rendered, is known as: -
✔✔Capitation
✔✔Aligning incentives has come to mean _________. -✔✔The appropriate addition of
some risk in the exchange of health care to a patient for some form of remuneration.
✔✔According to MedPAC, which option is a benefit or undesirable consequence of
bundling
payments? -✔✔-It allows Medicare to pay a set fee per hospitalization episode.
-It would provide the potential to improve efficiency and quality
-It would lead to underutilization of services
✔✔As the healthcare industry moves to control growth in medical spending, what
initiative can help hospitals maintain their margins? -✔✔Contract standardization
✔✔As the healthcare industry moves to control growth in medical spending, what
initiative can NOT help hospitals maintain their margins? -✔✔-Pay-for-performance
programs
-Health savings accounts
-Price transparency
✔✔Identify which initiatives are focused on in an effort to help increase an
organization's revenue/profit /margins. -✔✔-Health plan consolidation
-Payment policing and standardization of contract requirements
-Shift in volume and cost risk to hospitals
-Contract performance modeling
✔✔What are rating tiers? -✔✔Different rates charged on the basis of the number and
relationships
✔✔What is the role of reinsurance? -✔✔Reinsurance seeks to limit a policyholder's
liability for catastrophic claims
✔✔Which option is a major trend in case management? -✔✔-Shift from broad-based
toward more focused efforts
-Reduction of administrative costs
-Greater physician involvement
ANSWERS SURE A+
✔✔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.
✔✔Which of the following is an anticipated change in the relationships between
consumers and providers? -✔✔Providers will face many new service demands and
consumers will have virtually unfettered access to those services
✔✔What transition began as a result of the March 2010 healthcare reform legislation? -
✔✔A transition toward new models of health care delivery with corresponding changes
system financing and provider reimbursement.
✔✔Which statement is false concerning ABNs? -✔✔ABN began establishing new
requirements for managed care plans participating in the Medicare program.
✔✔Which Statement is TRUE concerning ABNs? -✔✔-ABNs are not required for
services that are never covered by Medicare.
-An ABN form notifies the patient before he or she receives the service that it may not
be
,covered by Medicare and that he or she will need to pay out of pocket.
-Although ABNs can have significant financial implications for the physician, they also
serve an important fraud and abuse compliance function.
✔✔What is the overall function of Medicaid? -✔✔The pay for medical assistance for
certain individuals and low-income families
✔✔Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: -✔✔Total
Medical Expenses divided by Total Premiums
✔✔Provider service organizations (PSOs) function like health maintenance
organizations (HMOs) in all of the following ways, EXCEPT: -✔✔Ties to the healthcare
delivery industry rather than the insurance industry
✔✔Provider service organizations (PSOs) function like health maintenance
organizations (HMOs) in all of the following ways: -✔✔-Risk pooling
-Capitalization
-Network management
✔✔Which of the following is a service provided by a well-managed third-party
administrator (TPA)? -✔✔-Administrative
-Utilization review (UR)
-Claims processing
✔✔What is tiering? -✔✔The ranking or classifying of one or more of the provider
delivery system components
✔✔Which option is a practice used to control costs of managed care? -✔✔-Making
advance payment to providers for all services needed to care for a member
-Combining services provided and bundling the associated charges
-Agreement between the payer and provider on reasonable payment for each service.
✔✔Which option is a risk involved in per diem payments? -✔✔-The risk to the insurance
company or health plan
-The risk to the hospital
-The risk when embracing per diem payments in complex case
✔✔Diagnosis-related group (DRG) is: -✔✔A payment category
✔✔How is the term carve-out used when discussing managed care? -✔✔To refer to
specific benefits or services
✔✔What is the term Coordination of Benefits (COB)? -✔✔A term used to describe how
payment is coordinated for patients who have coverage through two insurance policies
, ✔✔Which three components are used to determine the total RVU value for a service? -
✔✔-Malpractice expense
-Lowest market price for services used
-Medicare discounts
✔✔A fixed payment amount based upon the number of members assigned to a
provider, and does not vary based upon the number of services rendered, is known as: -
✔✔Capitation
✔✔Aligning incentives has come to mean _________. -✔✔The appropriate addition of
some risk in the exchange of health care to a patient for some form of remuneration.
✔✔According to MedPAC, which option is a benefit or undesirable consequence of
bundling
payments? -✔✔-It allows Medicare to pay a set fee per hospitalization episode.
-It would provide the potential to improve efficiency and quality
-It would lead to underutilization of services
✔✔As the healthcare industry moves to control growth in medical spending, what
initiative can help hospitals maintain their margins? -✔✔Contract standardization
✔✔As the healthcare industry moves to control growth in medical spending, what
initiative can NOT help hospitals maintain their margins? -✔✔-Pay-for-performance
programs
-Health savings accounts
-Price transparency
✔✔Identify which initiatives are focused on in an effort to help increase an
organization's revenue/profit /margins. -✔✔-Health plan consolidation
-Payment policing and standardization of contract requirements
-Shift in volume and cost risk to hospitals
-Contract performance modeling
✔✔What are rating tiers? -✔✔Different rates charged on the basis of the number and
relationships
✔✔What is the role of reinsurance? -✔✔Reinsurance seeks to limit a policyholder's
liability for catastrophic claims
✔✔Which option is a major trend in case management? -✔✔-Shift from broad-based
toward more focused efforts
-Reduction of administrative costs
-Greater physician involvement
