CSPR - Certified Specialist Payment Rep (HFMA) questions and answers with solutions

CSPR - Certified Specialist Payment Rep (HFMA) v v v v v v




questions and answers with solutions 2025
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Steps used to control costs of managed care include: - correct answer-Bundled codes
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v Capitation

Payer and Provider to agree on reasonable payment
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DRG is used to classify - correct answer-
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Inpatient admissions for the purpose of reimbursing hospitals for each case in a given category w/a ne gotiated
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fixed fee, regardless of the actual costs incurred
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Identify the various types of private health plan coverage - correct answer-HMO
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v Conventional

PPO and POS v v




HDHP/SO plans - high-deductible health plans with a savings option; Private -
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Include higher patient out-of-
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pocket expenditures for treatments that can serve to reduce utilization/costs.
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Managed care organizations (MCO) exist primarily in four forms: - correct answer- Health
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Maintenance Organizations (HMO)
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Preferred Provider Organizations (PPO) Point v v v v




v of Service (POS) Organizations Exclusive
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v Provider Organizations (EPO) v v




Identify the various types of government-sponsored health coverage: - correct answer-Medicare -
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Government; Beneficiaries enrolled in such plans, but, participation in these plans v v v v v v v v v v




v is voluntary.
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Medicaid

Medicaid Managed Care - v v v




Medicaid beneficiaries are required to select and enroll in a managed care plan. Medicare
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v Managed Care (a.k.a. Medicare Advantage Plans) v v v v v

,Identify some key drivers of increasing healthcare costs - correct answer-Demographics
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v Chronic Conditions v




Provider payment systems - v v v




Provider payment systems that are designed to reward volume rather than quality, outcomes, and pr
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evention
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Consumer Perceptions v




v Health Plan pressure v v




v PhysicianRelationships v




v Supply Chain v




Health Maintenance Organizations (HMO) - correct answer-Referrals
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v PCP

Patients must use an in-network provider for their services to be covered.
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Reimbursement - majority of services offered are reimbursed through capitation payments (PMPM) v v v v v v v v v v v




Medicare is composed of four parts: - correct answer-Part A - provides v v v v v v v v v v v




inpatient/hospital, hospice, and skilled nursing coverage
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Part B - provides outpatient/medical coverage
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Part C - an alternative way to receive your Medicare benefits (known as Medicare
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v Advantage)

Part D - prescription drug coverage
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HMO Act of 1973 - correct answer-
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The HMO Act of 1973 gave federally qualified HMOs the right to mandate that employers offer their p roduct
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to their employees under certain conditions. Mandating an employer meant that employers wh o had 25
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or more employees and were for-
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profit companies were required to make a dual choice available to their employees.
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Which of the following statements regarding employer-
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based health insurance in the United States is true? - correct answer-The real advent of employer-
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, based insurance came through Blue Cross, which was started by hospital associations during the Depr
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ession.
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The Health Maintenance Organization (HMO) Act of 1973 gave qualified HMOs the right to "mandate" an
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employer under certain conditions, meaning employers: - correct answer-
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Would have to offer HMO plans along side traditional fee-for-service medical plans.
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Which of the following is an anticipated change in the relationships between consumers and providers
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? - correct answer-
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Providers will face many new service demands and consumers will have virtually unfettered access to
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those services
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What transition began as a result of the March 2010 healthcare reform legislation? - correct answer- A
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transition toward new models of health care delivery with corresponding changes system financing and
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provider reimbursement.
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Which statement is false concerning ABNs? - correct answer-
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ABN began establishing new requirements for managed care plans participating in the Medicare progr am.
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Which Statement is TRUE concerning ABNs? - correct answer--
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ABNs are not required for services that are never covered by Medicare.
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-An ABN form notifies the patient before he or she receives the service that it may not be covered
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v by Medicare and that he or she will need to pay out of pocket.
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-Although ABNs can have significant financial implications for the physician, they also serve
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v an important fraud and abuse compliance function.
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What is the overall function of Medicaid? - correct answer-
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The pay for medical assistance for certain individuals and low-income families
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Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - correct answer- Total
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Medical Expenses divided by Total Premiums
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