CSPR - Certified Specialist Payment Rep (HFMA)
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Terms in this set (125)
Steps used to control costs of Bundled codes
managed care include: Capitation
Payer and Provider to agree on reasonable
payment
DRG is used to classify 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 HMO
health plan coverage 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.
Managed care organizations (MCO) Health Maintenance Organizations (HMO)
exist primarily in four forms: Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
,Identify the various types of Medicare - Government; Beneficiaries enrolled in
government‐sponsored health such plans, but, participation in these
coverage: plans is voluntary.
Medicaid
Medicaid Managed Care - Medicaid beneficiaries
are required to select and enroll in a managed care
plan.
Medicare Managed Care (a.k.a. Medicare
Advantage Plans)
Identify some key drivers of Demographics
increasing healthcare costs Chronic Conditions
Provider payment systems - Provider payment
systems that are designed to reward volume rather
than quality, outcomes, and prevention
Consumer Perceptions
Health Plan pressure
Physician Relationships
Supply Chain
Health Maintenance Organizations Referrals
(HMO) PCP
Patients must use an in-network provider for their
services to be covered.
Reimbursement - majority of services offered are
reimbursed through capitation payments (PMPM)
Medicare is composed of four parts: Part A - provides inpatient/hospital, hospice, and
skilled nursing coverage
Part B - provides outpatient/medical coverage
Part C - an alternative way to receive your
Medicare benefits (known as Medicare
Advantage)
Part D - prescription drug coverage
, HMO Act of 1973 The HMO Act of 1973 gave federally qualified
HMOs the right to mandate that employers offer
their product to their employees under certain
conditions. Mandating an employer meant that
employers who had 25 or more employees and
were for‐profit companies were required to make a
dual choice available to their employees.
Which of the following statements The real advent of employer-based insurance
regarding employer-based health came through Blue Cross, which was started by
insurance in the United States is hospital associations during the Depression.
true?
The Health Maintenance Would have to offer HMO plans along side
Organization (HMO) Act of 1973 traditional fee-for-service medical plans.
gave qualified HMOs the right to
"mandate" an employer under certain
conditions, meaning employers:
Which of the following is an Providers will face many new service demands and
anticipated change in the consumers will have virtually unfettered access to
relationships between consumers those services
and providers?
What transition began as a result of A transition toward new models of health care
the March 2010 healthcare reform delivery with corresponding changes system
legislation? financing and provider reimbursement.
Which statement is false concerning ABN began establishing new requirements for
ABNs? managed care plans participating in the Medicare
program.
Exam | Questions with 100% Correct Answers |
Verified | Latest Update 2026
Save
Terms in this set (125)
Steps used to control costs of Bundled codes
managed care include: Capitation
Payer and Provider to agree on reasonable
payment
DRG is used to classify 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 HMO
health plan coverage 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.
Managed care organizations (MCO) Health Maintenance Organizations (HMO)
exist primarily in four forms: Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
,Identify the various types of Medicare - Government; Beneficiaries enrolled in
government‐sponsored health such plans, but, participation in these
coverage: plans is voluntary.
Medicaid
Medicaid Managed Care - Medicaid beneficiaries
are required to select and enroll in a managed care
plan.
Medicare Managed Care (a.k.a. Medicare
Advantage Plans)
Identify some key drivers of Demographics
increasing healthcare costs Chronic Conditions
Provider payment systems - Provider payment
systems that are designed to reward volume rather
than quality, outcomes, and prevention
Consumer Perceptions
Health Plan pressure
Physician Relationships
Supply Chain
Health Maintenance Organizations Referrals
(HMO) PCP
Patients must use an in-network provider for their
services to be covered.
Reimbursement - majority of services offered are
reimbursed through capitation payments (PMPM)
Medicare is composed of four parts: Part A - provides inpatient/hospital, hospice, and
skilled nursing coverage
Part B - provides outpatient/medical coverage
Part C - an alternative way to receive your
Medicare benefits (known as Medicare
Advantage)
Part D - prescription drug coverage
, HMO Act of 1973 The HMO Act of 1973 gave federally qualified
HMOs the right to mandate that employers offer
their product to their employees under certain
conditions. Mandating an employer meant that
employers who had 25 or more employees and
were for‐profit companies were required to make a
dual choice available to their employees.
Which of the following statements The real advent of employer-based insurance
regarding employer-based health came through Blue Cross, which was started by
insurance in the United States is hospital associations during the Depression.
true?
The Health Maintenance Would have to offer HMO plans along side
Organization (HMO) Act of 1973 traditional fee-for-service medical plans.
gave qualified HMOs the right to
"mandate" an employer under certain
conditions, meaning employers:
Which of the following is an Providers will face many new service demands and
anticipated change in the consumers will have virtually unfettered access to
relationships between consumers those services
and providers?
What transition began as a result of A transition toward new models of health care
the March 2010 healthcare reform delivery with corresponding changes system
legislation? financing and provider reimbursement.
Which statement is false concerning ABN began establishing new requirements for
ABNs? managed care plans participating in the Medicare
program.
