CSPR - Certified Specialist Payment Rep (HFMA)EXAM,
comprehensive questions and verified answers ||
QUESTIONS WITH ACCURATE ANSWERS | GET IT RIGHT
|2025\2026!
Leave the first rating
Save
Students also studied
Flashcard sets Study guides
Missouri Public Adjustor/Solicitors E... Arkansas Life Insurance Exam CRCR (Certified Revenue Cycle Rep... He
Teacher 88 terms Teacher 93 terms Teacher 207 terms Te
Rosaline_Bundi Preview amazingmilante Preview githinjimugot Preview
Terms in this set (125)
Steps used to control costs of managed care include: Bundled codes
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 health plan HMO
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) exist primarily in Health Maintenance Organizations (HMO)
four forms: Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
, Identify the various types of government‐sponsored Medicare - Government; Beneficiaries enrolled in such plans, but, participation
health coverage: in these
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 increasing healthcare costs Demographics
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 (HMO) Referrals
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 regarding employer- The real advent of employer-based insurance came through Blue Cross, which
based health insurance in the United States is true? was started by hospital associations during the Depression.
The Health Maintenance Organization (HMO) Act of Would have to offer HMO plans along side traditional fee-for-service medical
1973 gave qualified HMOs the right to "mandate" an plans.
employer under certain conditions, meaning
employers:
Which of the following is an anticipated change in the Providers will face many new service demands and consumers will have
relationships between consumers and providers? virtually unfettered access to those services
comprehensive questions and verified answers ||
QUESTIONS WITH ACCURATE ANSWERS | GET IT RIGHT
|2025\2026!
Leave the first rating
Save
Students also studied
Flashcard sets Study guides
Missouri Public Adjustor/Solicitors E... Arkansas Life Insurance Exam CRCR (Certified Revenue Cycle Rep... He
Teacher 88 terms Teacher 93 terms Teacher 207 terms Te
Rosaline_Bundi Preview amazingmilante Preview githinjimugot Preview
Terms in this set (125)
Steps used to control costs of managed care include: Bundled codes
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 health plan HMO
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) exist primarily in Health Maintenance Organizations (HMO)
four forms: Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
, Identify the various types of government‐sponsored Medicare - Government; Beneficiaries enrolled in such plans, but, participation
health coverage: in these
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 increasing healthcare costs Demographics
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 (HMO) Referrals
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 regarding employer- The real advent of employer-based insurance came through Blue Cross, which
based health insurance in the United States is true? was started by hospital associations during the Depression.
The Health Maintenance Organization (HMO) Act of Would have to offer HMO plans along side traditional fee-for-service medical
1973 gave qualified HMOs the right to "mandate" an plans.
employer under certain conditions, meaning
employers:
Which of the following is an anticipated change in the Providers will face many new service demands and consumers will have
relationships between consumers and providers? virtually unfettered access to those services
