CSPR - Questions based on full course
Questions and Answers
1. ACA - ANS-Affordable Care Act
2. ACO - ANS-Accountable Care Organization
3. ACO Benefits - ANS-A system of providers and facilities that can work in concert to
care for a given patient population.
4. Advanced Beneficiary Notice (ABN) - ANS-document given to medicare beneficiaries
indicating the services medicare is unlikely to pay for
5. Aligning incentives - ANS-The appropriate addition of some risk in the exchange of
health care to a patient for some form of remuneration.
6. APCs - ANS-Ambulatory Payment Classifications
7. appropriate care - ANS-Right amount of Care was provided, setting usually means
the least intensive setting required, time usually refers to medical intervention at
the earliest possible time to prevent a bad situation, most appropriate cost
8. ARRA (American Recovery and Reinvestment Act) - ANS-These changes were also
extended not only to the covered entities, but also to business associates of the
covered entities. There is no limit to the total penalty in cases involving willful
neglect.
9. Balanced Budget Act of 1997 Objectives - ANS-Decrease Medicare reimbursement
levels, Mandate an end to the most areas of cost-based reimbursement and
Medicare Part C plans
10. Bundled Payment - ANS-The reimbursement of providers on the basis of expected
costs for clinically defined episodes of care
11. Bundled Payments - ANS-a model of reimbursement in which single payments are
made to multiple providers involved in an episode of care, creating a sense of
shared accountability among providers.
12. Capitation - ANS-A fixed payment amount based upon the number of members
assigned to a provider.
13. Capitation Payment - ANS-part of prospective payment in which healthcare
providers receive fixed monthly payments for services rendered regardless of
whether or not services are used
14. Capitation provider obligations - ANS-Understand costs of care, accept risks,
develop an appropriate data and system set, operational/financial, clinical
infrastructure, stop loss
15. Carve-outs - ANS-Sometimes refer to specific benefits or services that are
administered separately from the rest of the managed care plan and that may be
managed by other third parties.
16. Case Management - ANS-Component of UM that focuses on providing the
necessary medical care to a patient as cost effectively and medically appropriately
as possible.
, 17. Case management trends - ANS-Greater physician involvement, Reduction of
administrative costs, shift from broad-based toward more focused efforts
18. Case Rate Payment - ANS-Payments represent a fixed price for specified care by
paying an agreed upon rate for a specific healthcare service.
19. Catastrophic case management - ANS-It is used to manage diseases in patients with
very high costs of care
20. CDHP (consumer driven health plan) - ANS-Plans that try to pass decision making
onto you, employer gives money you spend
21. decision making is put on you, employers money given to you to spend, pay full price
22. Centers for Medicare and Medicaid Services (CMS) - ANS-Administers all federally
supported healthcare financing programs
23. claims adjudication - ANS-Term used in the insurance industry for the process of
paying or denying claims based on the patient's plan/coverage
24. Clean claim - ANS-A properly completed billing form UB-04 or CMS 1500 or a form
containing equivalent information, including complete ICD-10 and CPT-4 coding.
25. Clinical Staff - ANS-Must be familiar with payer requirements for appropriate
documentation of medical necessity and protocols for pre-authorizations.
26. CMS-1500 - ANS-most common health insurance claim form used to file claims for
physicians' services 837P
27. Co-insurance - ANS-A provision in the member's coverage that limits the amount of
coverage by the plan to a certain percentage, commonly 80%
28. COB -coordination of benefits - ANS-Management of payment between two or more
third-party payers for a service
29. COBRA (Consolidated Omnibus Budget Reconciliation Act) - ANS-Provides certain
former employees, retirees, spouses, former spouses, and dependent children the
right to temporary continuation of health coverage at group rates. 60 Days
30. Components used to determine the total RVU - ANS-Years of experience, Lowest
market price for services, Medicare discounts
31. Concurrent review - ANS-Managing care during the course of an inpatient
admission, with the goal of more efficient inpatient care
32. Confidentiality of health information - ANS-Requires MA plans to safeguard the
privacy of any information that identifies a particular enrolee.
33. Consumer Bill of Rights - ANS-codified the ethics of exchange between buyers and
sellers, including rights to safety, to be informed, to choose, and to be heard.
34. Contract negotiation evaluations should include what? - ANS-Member volumes by
product type, historical reimbursement levels by product type, Historical claims
payment and or submission problems
35. Conversion Factor - ANS-Multiplying the percentage in each tier by the number of
people actually estimated to be covered, and dividing that by the percentage times
the cost factor produces a premium weighting factor
36. coordination of benefits - ANS-A provision that helps determine the primary payer in
situations where an insured is covered by more than one policy, thus avoiding
claims overpayments.
Questions and Answers
1. ACA - ANS-Affordable Care Act
2. ACO - ANS-Accountable Care Organization
3. ACO Benefits - ANS-A system of providers and facilities that can work in concert to
care for a given patient population.
4. Advanced Beneficiary Notice (ABN) - ANS-document given to medicare beneficiaries
indicating the services medicare is unlikely to pay for
5. Aligning incentives - ANS-The appropriate addition of some risk in the exchange of
health care to a patient for some form of remuneration.
6. APCs - ANS-Ambulatory Payment Classifications
7. appropriate care - ANS-Right amount of Care was provided, setting usually means
the least intensive setting required, time usually refers to medical intervention at
the earliest possible time to prevent a bad situation, most appropriate cost
8. ARRA (American Recovery and Reinvestment Act) - ANS-These changes were also
extended not only to the covered entities, but also to business associates of the
covered entities. There is no limit to the total penalty in cases involving willful
neglect.
9. Balanced Budget Act of 1997 Objectives - ANS-Decrease Medicare reimbursement
levels, Mandate an end to the most areas of cost-based reimbursement and
Medicare Part C plans
10. Bundled Payment - ANS-The reimbursement of providers on the basis of expected
costs for clinically defined episodes of care
11. Bundled Payments - ANS-a model of reimbursement in which single payments are
made to multiple providers involved in an episode of care, creating a sense of
shared accountability among providers.
12. Capitation - ANS-A fixed payment amount based upon the number of members
assigned to a provider.
13. Capitation Payment - ANS-part of prospective payment in which healthcare
providers receive fixed monthly payments for services rendered regardless of
whether or not services are used
14. Capitation provider obligations - ANS-Understand costs of care, accept risks,
develop an appropriate data and system set, operational/financial, clinical
infrastructure, stop loss
15. Carve-outs - ANS-Sometimes refer to specific benefits or services that are
administered separately from the rest of the managed care plan and that may be
managed by other third parties.
16. Case Management - ANS-Component of UM that focuses on providing the
necessary medical care to a patient as cost effectively and medically appropriately
as possible.
, 17. Case management trends - ANS-Greater physician involvement, Reduction of
administrative costs, shift from broad-based toward more focused efforts
18. Case Rate Payment - ANS-Payments represent a fixed price for specified care by
paying an agreed upon rate for a specific healthcare service.
19. Catastrophic case management - ANS-It is used to manage diseases in patients with
very high costs of care
20. CDHP (consumer driven health plan) - ANS-Plans that try to pass decision making
onto you, employer gives money you spend
21. decision making is put on you, employers money given to you to spend, pay full price
22. Centers for Medicare and Medicaid Services (CMS) - ANS-Administers all federally
supported healthcare financing programs
23. claims adjudication - ANS-Term used in the insurance industry for the process of
paying or denying claims based on the patient's plan/coverage
24. Clean claim - ANS-A properly completed billing form UB-04 or CMS 1500 or a form
containing equivalent information, including complete ICD-10 and CPT-4 coding.
25. Clinical Staff - ANS-Must be familiar with payer requirements for appropriate
documentation of medical necessity and protocols for pre-authorizations.
26. CMS-1500 - ANS-most common health insurance claim form used to file claims for
physicians' services 837P
27. Co-insurance - ANS-A provision in the member's coverage that limits the amount of
coverage by the plan to a certain percentage, commonly 80%
28. COB -coordination of benefits - ANS-Management of payment between two or more
third-party payers for a service
29. COBRA (Consolidated Omnibus Budget Reconciliation Act) - ANS-Provides certain
former employees, retirees, spouses, former spouses, and dependent children the
right to temporary continuation of health coverage at group rates. 60 Days
30. Components used to determine the total RVU - ANS-Years of experience, Lowest
market price for services, Medicare discounts
31. Concurrent review - ANS-Managing care during the course of an inpatient
admission, with the goal of more efficient inpatient care
32. Confidentiality of health information - ANS-Requires MA plans to safeguard the
privacy of any information that identifies a particular enrolee.
33. Consumer Bill of Rights - ANS-codified the ethics of exchange between buyers and
sellers, including rights to safety, to be informed, to choose, and to be heard.
34. Contract negotiation evaluations should include what? - ANS-Member volumes by
product type, historical reimbursement levels by product type, Historical claims
payment and or submission problems
35. Conversion Factor - ANS-Multiplying the percentage in each tier by the number of
people actually estimated to be covered, and dividing that by the percentage times
the cost factor produces a premium weighting factor
36. coordination of benefits - ANS-A provision that helps determine the primary payer in
situations where an insured is covered by more than one policy, thus avoiding
claims overpayments.
