CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) CORRECT QUESTIONS AND ANSWERS GRADED A+ Steps used to control costs of managed care include: - correct answer Bundled codes Capitation Payer and Provider to agree on reasonable payment DRG is used to cla

CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) CORRECT QUESTIONS AND ANSWERS GRADED A+ Steps used to control costs of managed care include: - correct answer Bundled codes Capitation Payer and Provider to agree on reasonable payment DRG is used to classify - correct 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 - correct 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: - correct 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: - correct 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 - correct 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) - correct 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: - correct 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 - correct 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? - correct 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: - correct 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? - correct 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? - correct answer A transition toward new models of health care delivery with corresponding changes system financing and provider reimbursement. Which statement is false concerning ABNs? - correct answer ABN began establishing new requirements for managed care plans participating in the Medicare program. Which Statement is TRUE concerning ABNs? - correct 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? - correct 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: - correct 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: - correct 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: - correct answer -Risk pooling -Capitalization -Network management Which of the following is a service provided by a well-managed third-party administrator (TPA)? - correct answer -Administrative -Utilization review (UR) -Claims processing What is tiering? - correct 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? - correct 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? - correct answer -The risk to the insurance company or health plan -The risk to the hospital