Chfp Module 1 Certification Test.

CHFP MODULE 1 CERTIFICATION TEST



isooaoopre-
determinedooamountoothatootheoopatientoopaysoobeforeootheooinsureroobeginsootooopayoofo
rooservicesoo-ooans--deductible

aoopercentageooofootheooinsuranceoopaymentooamountoothatooisoopaidoobyootheoopatient,oo
alongoowithootheooamountoopaidoobyootheooinsurer.oo-ooans--coinsurance

aooflatooamountoothatootheoopatientoopaysooatooeachootimeooofooserviceoo-ooans--
copayment

paymentooalsoooincludesooamountsooforooservicesoothatooareoonotooincludedooinootheoopati
ent'soobenefitoodesignooandooamountsooforooservicesoobalanceoobilledoobyooout-of-
networkooproviders.ooPaymentsootypicallyoodoesoonotooincludeoopremiumoosharingoobyoot
heoopatient.oo-ooans--Out-of-pocketoopayment

Theooamountoopayableoooutooofoopocketooforoohealthcareooservices,oowhichoomayooinclud
esoodeductibles,oocopayments,oocoinsurance,ooamountsoopayableoobyootheoopatientooforo
oservicesoothatooareoonotooincludedooinootheoopatient'soobenefitoodesign,ooandooamountsoo
"balanceoobilled"oobyooout-of-
networkooproviders.ooHealthooinsuranceoopremiumsooconstituteooaooseparateoocategoryoo
ofoohealthcareoocostsooforoopatients,ooindependentooofoohealthcareooutilization.oo-ooans--
Costoo(toootheoopatient)

Theooexpenseoo(directooandooindirect)ooincurredootooodeliveroohealthcareooservicesootooop
atients.oo-ooans--Costsoo(toootheooprovider)

Theooamountoopayableootoootheooprovideroo(orooreimbursableootoootheoopatient)ooforooserv
icesoorendered.oo-ooans--Costoo(toootheoohealthooplan/insurer)

Theooexpenseoorelatedootoooprovidedoohealthoobenefitsoo(premiumsooorooclaimsoopaid)oo-
ooans--Costoo(toootheooemployer)


Theoodollarooamountooaooprovideroosetsooforooservicesoorenderedoobeforeoonegotiatingooa
nyoodiscounts.ooTheoochargeoocanoobeoodifferentoofromootheooamountoopaid.oo-ooans--
Charge

,Theoototalooamountooaooproviderooexpectsootooobeoopaidoobyoohealthooplans/
payersooandoopatientsooforoohealthcareooservices.oo-ooans--Price

Anooorganizationoothatoonegotiatesoooroosetsooratesooforooproviderooservices,oocollectsoor
evenueoothroughoopremiumoopaymentsooorootaxoodollars,ooprocessesooproviderooclaimsoo
forooservice,ooandoopaysooproviderooclaimsoousingoocollectedoopremiumooorootaxoorevenu
es.oo-ooans--HealthooPlan/Payer

Anooentity,ooorganization,ooorooindividualoothatoofurnishesooaoohealthcareooservice.oo-
ooans--Provider


Occursoowhenooaoohealthcareooprovideroobillsooaoopatientooforoochargesoo(otheroothanooco
payments,oocoinsuranceooorooanyooamountsoothatoomayooremainooonootheoopatient'sooann
ualoodeductible)oothatooexceedootheoohealthooplan'soopaymentooforooaoocoveredooservice.o
oIn-
networkooprovidersooareoocontractuallyooprohibitedoofromoobalanceoobillingoohealthooplano
omembers,oobutoobalanceoobillingoobyooout-of-networkooprovidersooisoocommon.oo-ooans--
BalanceooBilling

Inoohealthcare,ooreadilyooavailableooinformationooonootheoopriceooofoohealthcareooservices
oothat,ootogetheroowithoootherooinformation,oohelpsoodefineootheoovalueooofoothoseooservic
esooandooenablesoopatientsooandoootheroocareoopurchasersootoooidentify,oocompareooando
ochooseooprovidersoothatooofferootheoodesiredoolevelooofoovalueoo-ooans--
PriceooTransparency

Theooqualityooofooaoohealthcareooserviceooinoorelationootoootheoototaloopriceoopaidooforooth
eooserviceoobyoocareoopurchasers.oo-ooans--Value

theooflowooofoomoneyoobetweenootheoopatient,ootheooinsurer,ooandootheooproviderooofoohe
althcareooservicesoo-ooans--RevenueooCycle

functionoobetweenooaoohealthcareoofacilityoooroophysicianooandooanooinsurerooisoooneooofo
otheoomostooimportantooresourceoomanagementoochallengesooinootoday'soohealthcareooin
dustry.oo-ooans--BillingooandooCollection

Anooolderootermoousedootooodescribeoopaymentoobyooanooinsurerootoooaoohealthcareoofacil
ityoooroophysician.ooThisootermooisoousedoobecauseooaoophysicianoooroohealthcareoofacility
ooprovideroorenderooservicesootoooaoopatientooandoothenoosubmitsooclaimsooaooclaimootooo
anooinsurer.ooTheoohealthcareoofacilityoooroophysicianoowaitsooforooprocessingooofoothatooc
laimoobyootheooinsurer,ooandooultimatelyoorecievesoopayment,ooaoodeterminationooofoopay
mentooorooaoodenialoobyootheooinsurer.ooTodayooitooisoomoreoocommonootooouseootheooter
moopayment.oo-ooans--Reimbursement

Theoopriceoosetoobyooaoohealthcareoofacilityoooroophysicianooforootheirooservicesooisooreferr
edootoooasoo-ooans--ChargesooorooBilledooCharges

,Theoochargesoobyooaoohealthcareoofacilityoooroophysicianoorepresentootheooretailoopriceooa
ndooareoousuallyoocompiledooinooaoopriceoolistingooknownooasoo-ooans--Chargemaster

aoocharge-
basedoopaymentoomechanismooinoowhichooaooproviderooisoopaidooeitheroolistoopriceoo(fulloo
charges)ooorooaoopercentageooofoochargesoo(fulloochargesoolessooaoodiscount)ooforootheoo
specificooservicesoorendered.oo-ooans--Fee-for-service

Whatoodoesoofeeooforooserviceoopaymentooprovides?oo-ooans--
moreoounitsooofooserviceooinooorderootoooreceiveoomoreoopayments.

WhyoodoooHealthcareooFacilitiesoosetooRetailoopricesoosignificantlyooaboveooratesooactuall
yoopaidoobyoocommercialooinsurersooorootheoogovernment?oo-ooans--
1.ooAccessootoooContractedooPaymentooRates.
-
Rareoonotooallooinsurersooparticipateooinooprovideroonetworksoothatoogiveoothemooaccessoo
tooocontractedoopaymentoorates.ooSomeooautoooinsurers,ooliabilityooinsurersoooroocompani
esooprovidingootravelooinsuranceootooovisitorsoofromooabroadoostilloopayooaooprovider'sooful
loocharges.
2.ooPercent-of-ChargeooContracts
-Inoomarketsoowithoolittleoocompetition,oopercent-of-
chargeoocontractsooareoostilloocommon.ooTheoohigherootheooprice,ootheoohigherootheooperc
ent-of-
chargeoopayment,oounlessootheoocontractoolimitsooaooprovider'sooannualoopriceooincrease
s.
3.ooOutlierooProvisions
-
Someooinsuranceoocontactsoocontainooanoooutlierooprovisionoothatooentitlesooprovidersooto
ooanooadditionaloopaymentoo(aoolump-
sumoopaymentooorooaoopercentageooofooactualoochargesooaboveooaoothreshold)ooforooparti
cularlyoosickooandoohigh-costoopatients.

WhatooisootheoouseooandoobenefitsooofooCostooBasedooPayments?oo-ooans--
Theooonlyoouseooofoothisoomethodootodayooisooinooaoolimitedoosetooofoosmall,ooruraloohealth
careoofacilitiesooknownooasoocriticalooaccessoohospitals.ooThisoomechanismoohasoorarelyoo
beenoousedooforoophysicians.ooCost-
basedoopaymentoocallsooforootheooinsurerootooopayootheoohealthcareooprovideroobasedooo
nootheoocostsooofooprovidingooservices,oowithooaoonominalooallowanceooforoomargin.

WhatooisootheooMedicareooprogramoobeganoowithooaoopaymentoomechanismootooohealthc
areoofacilitiesoothatoohasoosinceoobeenoonearlyooeliminatedoofromootheoohealthcareooindus
tryoo—oo-ooans--CostoobasedooPayment

Whichooofootheoofollowingoowouldoobenefitootheoomostoofromooaoocost-
basedoopaymentoomethod?oo-ooans--Theoohealthcareooprovider

, That'sooright!ooLet'soounderstandoohow.
Theoopaymentoomechanismooisooadvantageousooforoohealthcareooproviders,ooasoothereooi
sooaoohigheroolikelihoodoothatooalloocostsoowilloobeoopaid,ooandoothereooisoonoooincentiveoot
ooobeooefficientooinooprovidingoocare,oosinceoocostsoowilloobeooreimbursedoobyootheooinsur
er.ooTheoorapidooescalationooofoohealthcareoocostsooinootheooU.S.ooafterootheoostartooofooc
ost-
basedoopaymentooinooMedicareooandooMedicaidooprogramsooledootoootheooimplementatio
nooofootheooProspectiveooPaymentooSystemoo(PPS)ooofoopayingooacuteoocareoohealthcare
ooprovidersooforooinpatientooservicesooinoo1983ooandoooutpatientooservicesooinoo2000.ooSi
nceoothen,ooCMSoohasoointroducedooprospectiveoopaymentoosystemsooforoomostoootheroo
typesooofooinstitutionaloohealthcareooproviders

Cost-Basedoopaymentoodecreasedooneedooforooprovidersootooobeooefficient.

MountainsideooHealthooPlanooisooevaluatingooitsoopaymentooofoohospitalsooinooitsoocurrent
ooserviceooarea.ooItooisoolookingootoooreduceooitsoocostsooperoopatientooandoostabilizeooitsoo
overalloopaymentsootooohospitals.ooWhichooofootheoofollowingoopaymentoomethodsoowould
oobeooleastooeffectiveooforootheoohealthooplanootooomeetootheseooobjectives?oo-ooans--
Cost-basedoopayment

Youooselectedootheoocorrectooanswer.ooCost-
basedoopaymentooisootheooleastoopredictableoomodelooforooaoohealthooplanooandoohasooth
eoogreatestooriskooofooincreasedoocostoobecauseooitooisoodependentooonootheoohospital'soo
abilityootooomanageoooperatingoocosts.

Theootableoobelowooshowsootheoomethodsoorankedoofromoomostoopredictableootoooleastoo
predictable.

Whatooareootheoo5oomainootypesooofooprospectiveoopaymentsoousedooinootoday'soohealthc
areoomarket?oo-ooans--1.ooDRGoohealthcareooprovider
2.ooPerooProcedure
3.ooCaseoorateoo-oohealthcareooprovideroooroophysician
4.ooPeroodiemoo-oohealthcareooprovider
5.ooBundledoopaymentoo-oohealthcareooprovider,oophysiciansooandoopost-
acuteooproviders

Aoopaymentoobasedooonootheoopatient'soodiagnosisooisooknownooasooaoo-ooans--
(DRG)ooDiagnosisooRelatedooGroup

Whatooisootheoomostoowidelyoousedooinoopaymentsootooohealthcareooproviders.oo-ooans--
(DRG)'s

isooaooclassificationooofooaoodiseaseooorooinjuryoointooooneooofooapproximatelyoo750oodiffer
entoocategories.

Theooamountoopaidooisooaooflatoorateooperoodischargeooandooisooadjustedoobasedooon: