CSPR - Certified Specialist Payment Rep (HFMA) with correct answers

CSPR - Certified Specialist Payment
Rep (HFMA) with correct answers

Steps used to control costs of managed care include: - answersBundled codes
f f f f f f f f f f f



Capitation f



Payer and Provider to agree on reasonable payment
f f f f f f f




DRG is used to classify - answersInpatient admissions for the purpose of reimbursing
f f f f f f f f f f f f



hospitals for each case in a given category w/a negotiated fixed fee, regardless of the actual
f f f f f f f f f f f f f f f f



costs incurred
f f




Identify the various types of private health plan coverage - answersHMO
f f f f f f f f f f



Conventional
PPO and POS
f f



HDHP/SO plans - high-deductible health plans with a savings option; Private - Include
f f f f f f f f f f f f



higher patient out-of-pocket expenditures for treatments that can serve to reduce
f f f f f f f f f f f



utilization/costs.
f




Managed care organizations (MCO) exist primarily in four forms: - answersHealth
f f f f f f f f f f



Maintenance Organizations (HMO)
f f f



Preferred Provider Organizations (PPO) f f f



Point of Service (POS) Organizations
f f f f



Exclusive Provider Organizations (EPO) f f f




Identify the various types of government‐sponsored health coverage: - answersMedicare -
f f f f f f f f f f



Government; Beneficiaries enrolled in such plans, but, participation in these
f f f f f f f f f f



plans is voluntary.
f f



Medicaid
Medicaid Managed Care - Medicaid beneficiaries are required to select and enroll in a
f f f f f f f f f f f f f



managed care plan.
f f f



Medicare Managed Care (a.k.a. Medicare Advantage Plans)
f f f f f f




Identify some key drivers of increasing healthcare costs - answersDemographics
f f f f f f f f f



Chronic Conditions f



Provider payment systems - Provider payment systems that are designed to reward volume
f f f f f f f f f f f f



rather than quality, outcomes, and prevention
f f f f f f



Consumer Perceptions f



Health Plan pressure f f



Physician Relationships f



Supply Chain f

,Health Maintenance Organizations (HMO) - answersReferrals
f f f f f



PCP
Patients must use an in-network provider for their services to be covered.
f f f f f f f f f f f



Reimbursement - majority of services offered are reimbursed through capitation payments f f f f f f f f f f



(PMPM)
f




Medicare is composed of four parts: - answersPart A - provides inpatient/hospital, hospice,
f f f f f f f f f f f f



and skilled nursing coverage
f f f f



Part B - provides outpatient/medical coverage
f f f f f



Part C - an alternative way to receive your Medicare benefits (known as Medicare
f f f f f f f f f f f f f



Advantage)
Part D - prescription drug coverage
f f f f f




HMO Act of 1973 - answersThe HMO Act of 1973 gave federally qualified HMOs the right to
f f f f f f f f f f f f f f f f



mandate that employers offer their product to their employees under certain conditions.
f f f f f f f f f f f f



Mandating an employer meant that employers who had 25 or more employees and were for‐
f f f f f f f f f f f f f f f



profit companies were required to make a dual choice available to their employees.
f f f f f f f f f f f f




Which of the following statements regarding employer-based health insurance in the United
f f f f f f f f f f f



States is true? - answersThe real advent of employer-based insurance came through Blue
f f f f f f f f f f f f f



Cross, which was started by hospital associations during the Depression.
f f f f f f f f f f




The Health Maintenance Organization (HMO) Act of 1973 gave qualified HMOs the right to
f f f f f f f f f f f f f



"mandate" an employer under certain conditions, meaning employers: - answersWould
f f f f f f f f f f



have to offer HMO plans along side traditional fee-for-service medical plans.
f f f f f f f f f f f




Which of the following is an anticipated change in the relationships between consumers and
f f f f f f f f f f f f f



providers? - answersProviders will face many new service demands and consumers will
f f f f f f f f f f f f



have virtually unfettered access to those services
f f f f f f f




What transition began as a result of the March 2010 healthcare reform legislation? -
f f f f f f f f f f f f f



answersA transition toward new models of health care delivery with corresponding changes
f f f f f f f f f f f f



system financing and provider reimbursement.
f f f f f




Which statement is false concerning ABNs? - answersABN began establishing new
f f f f f f f f f f



requirements for managed care plans participating in the Medicare program.
f f f f f f f f f f




Which Statement is TRUE concerning ABNs? - answers-ABNs are not required for services
f f f f f f f f f f f f



that are never covered by Medicare.
f f f f f f



-An ABN form notifies the patient before he or she receives the service that it may not be
f f f f f f f f f f f f f f f f f



covered by Medicare and that he or she will need to pay out of pocket.
f f f f f f f f f f f f f f



-Although ABNs can have significant financial implications for the physician, they also
f f f f f f f f f f f



serve an important fraud and abuse compliance function.
f f f f f f f




What is the overall function of Medicaid? - answersThe pay for medical assistance for
f f f f f f f f f f f f f



certain individuals and low-income families
f f f f f

, Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - answersTotal
f f f f f f f f f f f f f



Medical Expenses divided by Total Premiums
f f f f f f




Provider service organizations (PSOs) function like health maintenance organizations
f f f f f f f f



(HMOs) in all of the following ways, EXCEPT: - answersTies to the healthcare delivery
f f f f f f f f f f f f f f



industry rather than the insurance industry
f f f f f f




Provider service organizations (PSOs) function like health maintenance organizations
f f f f f f f f



(HMOs) in all of the following ways: - answers-Risk pooling
f f f f f f f f f f



-Capitalization
-Network management f




Which of the following is a service provided by a well-managed third-party administrator
f f f f f f f f f f f f



(TPA)? - answers-Administrative
f f f



-Utilization review (UR) f f f



-Claims processing f




What is tiering? - answersThe ranking or classifying of one or more of the provider delivery
f f f f f f f f f f f f f f f



system components
f f




Which option is a practice used to control costs of managed care? - answers-Making
f f f f f f f f f f f f f



advance payment to providers for all services needed to care for a member
f f f f f f f f f f f f f



-Combining services provided and bundling the associated charges f f f f f f f



-Agreement between the payer and provider on reasonable payment for each service.
f f f f f f f f f f f




Which option is a risk involved in per diem payments? - answers-The risk to the insurance
f f f f f f f f f f f f f f f



company or health plan
f f f f



-The risk to the hospital
f f f f



-The risk when embracing per diem payments in complex case
f f f f f f f f f




Diagnosis-related group (DRG) is: - answersA payment category f f f f f f f




How is the term carve-out used when discussing managed care? - answersTo refer to
f f f f f f f f f f f f f



specific benefits or services
f f f f




What is the term Coordination of Benefits (COB)? - answersA term used to describe how
f f f f f f f f f f f f f f



payment is coordinated for patients who have coverage through two insurance policies
f f f f f f f f f f f f




Which three components are used to determine the total RVU value for a service? -
f f f f f f f f f f f f f f



answers-Malpractice expense
f f



-Lowest market price for services used
f f f f f f



-Medicare discounts f