CSBI HFMA 2026 COMPREHENSIVE EXAM
SCRIPT COMPLETE ANSWERS
◉Provider service organizations (PSOs) function like health
maintenance organizations (HMOs) in all of the following ways:.
Answer: -Risk pooling
-Capitalization
-Network management
◉Which of the following is a service provided by a well-managed
third-party administrator (TPA)?. Answer: -Administrative
-Utilization review (UR)
-Claims processing
◉What is tiering?. Answer: 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?.
Answer: -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?. Answer: -
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:. Answer: A payment category
◉How is the term carve-out used when discussing managed care?.
Answer: To refer to specific benefits or services
◉What is the term Coordination of Benefits (COB)?. Answer: 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?. Answer: -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:. Answer: Capitation
◉Aligning incentives has come to mean _________.. Answer: 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?. Answer: -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?.
Answer: Contract standardization
◉As the healthcare industry moves to control growth in medical
spending, what initiative can NOT help hospitals maintain their
margins?. Answer: -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.. Answer: -
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?. Answer: Different rates charged on the
basis of the number and relationships
◉What is the role of reinsurance?. Answer: Reinsurance seeks to
limit a policyholder's liability for catastrophic claims
◉Which option is a major trend in case management?. Answer: -
Shift from broad-based toward more focused efforts
-Reduction of administrative costs
-Greater physician involvement
◉What type of provider authorization is applied in emergency
cases, where prior authorization is impossible?. Answer: Concurrent
◉What is utilization management (UM)?. Answer: A tool to control
the costs of providing healthcare services to enrollees
SCRIPT COMPLETE ANSWERS
◉Provider service organizations (PSOs) function like health
maintenance organizations (HMOs) in all of the following ways:.
Answer: -Risk pooling
-Capitalization
-Network management
◉Which of the following is a service provided by a well-managed
third-party administrator (TPA)?. Answer: -Administrative
-Utilization review (UR)
-Claims processing
◉What is tiering?. Answer: 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?.
Answer: -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?. Answer: -
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:. Answer: A payment category
◉How is the term carve-out used when discussing managed care?.
Answer: To refer to specific benefits or services
◉What is the term Coordination of Benefits (COB)?. Answer: 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?. Answer: -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:. Answer: Capitation
◉Aligning incentives has come to mean _________.. Answer: 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?. Answer: -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?.
Answer: Contract standardization
◉As the healthcare industry moves to control growth in medical
spending, what initiative can NOT help hospitals maintain their
margins?. Answer: -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.. Answer: -
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?. Answer: Different rates charged on the
basis of the number and relationships
◉What is the role of reinsurance?. Answer: Reinsurance seeks to
limit a policyholder's liability for catastrophic claims
◉Which option is a major trend in case management?. Answer: -
Shift from broad-based toward more focused efforts
-Reduction of administrative costs
-Greater physician involvement
◉What type of provider authorization is applied in emergency
cases, where prior authorization is impossible?. Answer: Concurrent
◉What is utilization management (UM)?. Answer: A tool to control
the costs of providing healthcare services to enrollees
