CSPR - Certified Specialist Payment Rep
(HFMA) Questions And Answers With
Verified Solutions 100% Correct Rated A+
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 with 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 (Includes 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 (also known as 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 (Primary Care Provider)
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 alongside 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 in 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.
(HFMA) Questions And Answers With
Verified Solutions 100% Correct Rated A+
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 with 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 (Includes 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 (also known as 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 (Primary Care Provider)
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 alongside 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 in 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.
