Certified Healthcare Financial Professional
Exam ACTUAL QUESTIONS AND
CORRECT ANSWERS
Provider - general - CORRECT ANSWERS✅✅a licensed professional or entity that
provides a medical service to a patient.
Facility provider - CORRECT ANSWERS✅✅an acute care hospital, long-term care
hospital, inpatient rehab hospital, psychiatric facility, skilled nursing facility, assisted living
facility, home health agency, hospice agency, clinic or ambulatory surgery center.
Professional provider - CORRECT ANSWERS✅✅a physician, pharmacist, registered nurse
or allied professional provider (APP) rendering a medical service to a patient. (Clinical social
workers and physical therapists are examples of APPs).
Primary care - CORRECT ANSWERS✅✅trained and board- certified in family practice,
general practice, general internal medicine and pediatrics. They frequently coordinate a
patient's care and refer patients to specialists.
Specialist - CORRECT ANSWERS✅✅a physician who specializes in a specific disease,
body system or type of healthcare.
Third-party payer - CORRECT ANSWERS✅✅a health insurance plan paying a provider for
healthcare services delivered to its insured patients. The other two parties in a healthcare
business transaction are the patient and the provider.
Out-of-pocket payment - CORRECT ANSWERS✅✅Payments made by patients in addition
to what their health insurance plan pays
Deductible - CORRECT ANSWERS✅✅a pre-determined amount that the patient pays
before the insurer begins to pay for service.
Coinsurance - CORRECT ANSWERS✅✅a percentage of the insurance payment amount
that is paid by the patient, along with the amount paid by the insurer.
,Copay - CORRECT ANSWERS✅✅a flat amount that a patient pays at each time of service.
Claim - CORRECT ANSWERS✅✅another word for a bill for healthcare services provided.
Pre-authorization - CORRECT ANSWERS✅✅Insurers may require providers to contact
them to pre- authorize certain high-cost services before treatment. An acknowledgement by
the payer that it considers the service medically necessary and will pay for it.
Benefit payment - CORRECT ANSWERS✅✅Once the insurer has determined the claim is
appropriate, a payment is made to the provider. This payment is officially termed a
______________ _____________.
Beneficiary - CORRECT ANSWERS✅✅Insurers usually refer to the patient for which
services are paid as the _____________.
Covered benefit - CORRECT ANSWERS✅✅The services for which the insurer will pay
Denial - CORRECT ANSWERS✅✅The insurer may determine that the claim from the
provider is not a covered benefit and will not pay the claim.
Remittance advice - CORRECT ANSWERS✅✅a written explanation accompanying an
insurer's payment (or non-payment) of a patient account to a provider. The copy sent to the
patient is known an Explanation of Benefits (EOB).
Medicare Part A (Hospital Insurance) - CORRECT ANSWERS✅✅one of two parts of the
original Medicare program established by Title XVIII of the Social Security Act in 1965. It
pays for hospital inpatient, skilled nursing facility, hospice and some home health care. It's is
a premium-free benefit funded by FICA payroll deductions. "Categorical" eligibility starts on
when a U.S citizen who paid FICA taxes for at least 40 calendar quarters turns 65. Disabled
individuals under 65 who have received Social Security for 24 months also qualify for
Medicare. Funded by a 2.9% payroll tax.
Medicare Part B (Supplemental Medical Insurance) - CORRECT ANSWERS✅✅The
"voluntary" part of original Medicare. It pays for physician services, outpatient hospital and
, clinic care and some home health services. While beneficiaries over 65 pay a monthly
premium tied to their prior year income, about 75% of the total cost is paid from general tax
revenues. Since Part B is voluntary and not everyone may qualify for Part A, it is possible for
a patient to have Medicare Part B but not Medicare Part A or vice versa.
Advantage (Medicare Part C) - CORRECT ANSWERS✅✅commercial insurance plans
(HMOs, PPOs or fee-for- service plans) that offer Medicare beneficiaries an alternative to
traditional Medicare. About 30% of Medicare beneficiaries select Advantage plans because
benefits frequently exceed those of traditional Medicare. Beneficiaries pay the normal
monthly Part B premium to CMS and sometimes also a separate Medicare Advantage
premium to the commercial payer. Most plans have narrower provider choices than
traditional Medicare. CMS pays Medicare Advantage plans a fixed, risk-adjusted monthly fee
per beneficiary that slightly exceeds the estimated cost of providing similar services under
traditional Medicare.
Medicare Prescription Drug benefit (Medicare Part D) - CORRECT
ANSWERS✅✅launched in 2006, covers prescription medications for Medicare
beneficiaries. Commercial plans have monthly premiums and vary in the cost and kinds of
drugs covered. Plans are allowed to negotiate discounts with drug manufacturers.
Centers for Medicare and Medicaid Services (CMS) - CORRECT ANSWERS✅✅The
federal government, through the Centers for Medicare and Medicaid Services or CMS,
oversees all parts of the Medicare and Medicaid programs. CMS can waive a state's
requirement to participate in traditional Medicaid if the state offers beneficiaries plans with
better benefits.
Medicare Cost Report - CORRECT ANSWERS✅✅institutional providers participating in
the Medicare program must submit to their Medicare Administrative Contractor. For
providers paid prospectively, the cost report determines reimbursement for certain add-on
payments but does not affect the overall payment rate. For providers paid retrospectively, the
cost report determines the payment rate. CMS uses cost report data to update DRG and APC
weights and determine market basket updates.
Medicare Trust Fund - CORRECT ANSWERS✅✅The pool of FICA taxes that pays for
Medicare Part A and B. Unless Medicare is reformed or payroll taxes are increased, this is
expected to be depleted within the next ten years.
Exam ACTUAL QUESTIONS AND
CORRECT ANSWERS
Provider - general - CORRECT ANSWERS✅✅a licensed professional or entity that
provides a medical service to a patient.
Facility provider - CORRECT ANSWERS✅✅an acute care hospital, long-term care
hospital, inpatient rehab hospital, psychiatric facility, skilled nursing facility, assisted living
facility, home health agency, hospice agency, clinic or ambulatory surgery center.
Professional provider - CORRECT ANSWERS✅✅a physician, pharmacist, registered nurse
or allied professional provider (APP) rendering a medical service to a patient. (Clinical social
workers and physical therapists are examples of APPs).
Primary care - CORRECT ANSWERS✅✅trained and board- certified in family practice,
general practice, general internal medicine and pediatrics. They frequently coordinate a
patient's care and refer patients to specialists.
Specialist - CORRECT ANSWERS✅✅a physician who specializes in a specific disease,
body system or type of healthcare.
Third-party payer - CORRECT ANSWERS✅✅a health insurance plan paying a provider for
healthcare services delivered to its insured patients. The other two parties in a healthcare
business transaction are the patient and the provider.
Out-of-pocket payment - CORRECT ANSWERS✅✅Payments made by patients in addition
to what their health insurance plan pays
Deductible - CORRECT ANSWERS✅✅a pre-determined amount that the patient pays
before the insurer begins to pay for service.
Coinsurance - CORRECT ANSWERS✅✅a percentage of the insurance payment amount
that is paid by the patient, along with the amount paid by the insurer.
,Copay - CORRECT ANSWERS✅✅a flat amount that a patient pays at each time of service.
Claim - CORRECT ANSWERS✅✅another word for a bill for healthcare services provided.
Pre-authorization - CORRECT ANSWERS✅✅Insurers may require providers to contact
them to pre- authorize certain high-cost services before treatment. An acknowledgement by
the payer that it considers the service medically necessary and will pay for it.
Benefit payment - CORRECT ANSWERS✅✅Once the insurer has determined the claim is
appropriate, a payment is made to the provider. This payment is officially termed a
______________ _____________.
Beneficiary - CORRECT ANSWERS✅✅Insurers usually refer to the patient for which
services are paid as the _____________.
Covered benefit - CORRECT ANSWERS✅✅The services for which the insurer will pay
Denial - CORRECT ANSWERS✅✅The insurer may determine that the claim from the
provider is not a covered benefit and will not pay the claim.
Remittance advice - CORRECT ANSWERS✅✅a written explanation accompanying an
insurer's payment (or non-payment) of a patient account to a provider. The copy sent to the
patient is known an Explanation of Benefits (EOB).
Medicare Part A (Hospital Insurance) - CORRECT ANSWERS✅✅one of two parts of the
original Medicare program established by Title XVIII of the Social Security Act in 1965. It
pays for hospital inpatient, skilled nursing facility, hospice and some home health care. It's is
a premium-free benefit funded by FICA payroll deductions. "Categorical" eligibility starts on
when a U.S citizen who paid FICA taxes for at least 40 calendar quarters turns 65. Disabled
individuals under 65 who have received Social Security for 24 months also qualify for
Medicare. Funded by a 2.9% payroll tax.
Medicare Part B (Supplemental Medical Insurance) - CORRECT ANSWERS✅✅The
"voluntary" part of original Medicare. It pays for physician services, outpatient hospital and
, clinic care and some home health services. While beneficiaries over 65 pay a monthly
premium tied to their prior year income, about 75% of the total cost is paid from general tax
revenues. Since Part B is voluntary and not everyone may qualify for Part A, it is possible for
a patient to have Medicare Part B but not Medicare Part A or vice versa.
Advantage (Medicare Part C) - CORRECT ANSWERS✅✅commercial insurance plans
(HMOs, PPOs or fee-for- service plans) that offer Medicare beneficiaries an alternative to
traditional Medicare. About 30% of Medicare beneficiaries select Advantage plans because
benefits frequently exceed those of traditional Medicare. Beneficiaries pay the normal
monthly Part B premium to CMS and sometimes also a separate Medicare Advantage
premium to the commercial payer. Most plans have narrower provider choices than
traditional Medicare. CMS pays Medicare Advantage plans a fixed, risk-adjusted monthly fee
per beneficiary that slightly exceeds the estimated cost of providing similar services under
traditional Medicare.
Medicare Prescription Drug benefit (Medicare Part D) - CORRECT
ANSWERS✅✅launched in 2006, covers prescription medications for Medicare
beneficiaries. Commercial plans have monthly premiums and vary in the cost and kinds of
drugs covered. Plans are allowed to negotiate discounts with drug manufacturers.
Centers for Medicare and Medicaid Services (CMS) - CORRECT ANSWERS✅✅The
federal government, through the Centers for Medicare and Medicaid Services or CMS,
oversees all parts of the Medicare and Medicaid programs. CMS can waive a state's
requirement to participate in traditional Medicaid if the state offers beneficiaries plans with
better benefits.
Medicare Cost Report - CORRECT ANSWERS✅✅institutional providers participating in
the Medicare program must submit to their Medicare Administrative Contractor. For
providers paid prospectively, the cost report determines reimbursement for certain add-on
payments but does not affect the overall payment rate. For providers paid retrospectively, the
cost report determines the payment rate. CMS uses cost report data to update DRG and APC
weights and determine market basket updates.
Medicare Trust Fund - CORRECT ANSWERS✅✅The pool of FICA taxes that pays for
Medicare Part A and B. Unless Medicare is reformed or payroll taxes are increased, this is
expected to be depleted within the next ten years.
