CSBI HFMA PRACTICE QUESTIONS AND
DETAILED SOLUTIONS
◉ 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
◉ 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.
◉ 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)
-Claims processing
◉ What is tiering?
Answer: The ranking or classifying of one or more of the provider
delivery system components
◉ Which option is a practice used to control costs of managed care?
Answer: -Making advance payment to providers for all services
needed to care for a member
-Combining services provided and bundling the associated charges
-Agreement between the payer and provider on reasonable payment
for each service.
◉ Which option is a risk involved in per diem payments?
Answer: -The risk to the insurance company or health plan
-The risk to the hospital
-The risk when embracing per diem payments in complex case
DETAILED SOLUTIONS
◉ 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
◉ 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.
◉ 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)
-Claims processing
◉ What is tiering?
Answer: The ranking or classifying of one or more of the provider
delivery system components
◉ Which option is a practice used to control costs of managed care?
Answer: -Making advance payment to providers for all services
needed to care for a member
-Combining services provided and bundling the associated charges
-Agreement between the payer and provider on reasonable payment
for each service.
◉ Which option is a risk involved in per diem payments?
Answer: -The risk to the insurance company or health plan
-The risk to the hospital
-The risk when embracing per diem payments in complex case
