1|Page
CSPR - Certified Specialist Payment Rep (HFMA)
EXAM ||VERIFIED EXAM!!!|| MOST RECENT EXAM
ACTUAL COMPLETE REAL EXAM QUESTIONS AND
CORRECT ANSWERS (VERIFIED ANSWERS)
ALREADY GRADED A+ | GUARANTEED SUCCESS!!
NEWEST EXAM!!!
Which of the following statements regarding employer-
based health insurance in the United States is true? -
Answer-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: - Answer-
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? -
Answer-Providers will face many new service demands
and consumers will have virtually unfettered access to
those services
,2|Page
What transition began as a result of the March 2010
healthcare reform legislation? - Answer-A transition toward
new models of health care delivery with corresponding
changes system financing and provider reimbursement.
Which statement is false concerning ABNs? - Answer-ABN
began establishing new requirements for managed care
plans participating in the Medicare program.
Which Statement is TRUE concerning ABNs? - Answer--
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.
,3|Page
What is the overall function of Medicaid? - Answer-The
pay for medical assistance for certain individuals and low-
income families
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is
defined as: - Answer-Total Medical Expenses divided by
Total Premiums
Provider service organizations (PSOs) function like health
maintenance organizations (HMOs) in all of the following
ways, EXCEPT: - Answer-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: - 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)
, 4|Page
-Claims processing
What is tiering? - Answer-The ranking or classifying of one
or more of the provider delivery system components
Steps used to control costs of managed care include: -
Answer-Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - Answer-Inpatient admissions for
the purpose of reimbursing hospitals for each case in a
given category w/a negotiated fixed fee, regardless of the
actual costs incurred
Identify the various types of private health plan coverage -
Answer-HMO
Conventional
PPO and POS
HDHP/SO plans - high-deductible health plans with a
savings option; Private - Include higher patient out-of-
pocket expenditures for treatments that can serve to
reduce utilization/costs.
CSPR - Certified Specialist Payment Rep (HFMA)
EXAM ||VERIFIED EXAM!!!|| MOST RECENT EXAM
ACTUAL COMPLETE REAL EXAM QUESTIONS AND
CORRECT ANSWERS (VERIFIED ANSWERS)
ALREADY GRADED A+ | GUARANTEED SUCCESS!!
NEWEST EXAM!!!
Which of the following statements regarding employer-
based health insurance in the United States is true? -
Answer-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: - Answer-
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? -
Answer-Providers will face many new service demands
and consumers will have virtually unfettered access to
those services
,2|Page
What transition began as a result of the March 2010
healthcare reform legislation? - Answer-A transition toward
new models of health care delivery with corresponding
changes system financing and provider reimbursement.
Which statement is false concerning ABNs? - Answer-ABN
began establishing new requirements for managed care
plans participating in the Medicare program.
Which Statement is TRUE concerning ABNs? - Answer--
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.
,3|Page
What is the overall function of Medicaid? - Answer-The
pay for medical assistance for certain individuals and low-
income families
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is
defined as: - Answer-Total Medical Expenses divided by
Total Premiums
Provider service organizations (PSOs) function like health
maintenance organizations (HMOs) in all of the following
ways, EXCEPT: - Answer-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: - 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)
, 4|Page
-Claims processing
What is tiering? - Answer-The ranking or classifying of one
or more of the provider delivery system components
Steps used to control costs of managed care include: -
Answer-Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - Answer-Inpatient admissions for
the purpose of reimbursing hospitals for each case in a
given category w/a negotiated fixed fee, regardless of the
actual costs incurred
Identify the various types of private health plan coverage -
Answer-HMO
Conventional
PPO and POS
HDHP/SO plans - high-deductible health plans with a
savings option; Private - Include higher patient out-of-
pocket expenditures for treatments that can serve to
reduce utilization/costs.
