CSPR - CERTIFIED SPECIALIST PAYMENT REP
(HFMA)
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.
Managed care organizations (MCO) exist primarily in four
forms: - ANSWER ->Health Maintenance Organizations
(HMO)
,Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Identify the various types of government‐sponsored
health coverage: - ANSWER ->Medicare - Government;
Beneficiaries enrolled in such plans, but, participation 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 -
ANSWER ->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) - ANSWER -
>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: - ANSWER ->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 - ANSWER ->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-
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
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.
(HFMA)
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.
Managed care organizations (MCO) exist primarily in four
forms: - ANSWER ->Health Maintenance Organizations
(HMO)
,Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Identify the various types of government‐sponsored
health coverage: - ANSWER ->Medicare - Government;
Beneficiaries enrolled in such plans, but, participation 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 -
ANSWER ->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) - ANSWER -
>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: - ANSWER ->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 - ANSWER ->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-
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
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.
