CSPR - Certified Specialist Payment Rep (HFMA)
questions with correct answers
1. Steps used to control costs of managed care include :Answer:
Bundled codes Capitation
Payer and Provider to agree on reasonable payment
2. 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
3. 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.
4. 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)
5. 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)
6. 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
7. 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)
8. 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
9. 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.
10. Which of the following statements regarding employer-based health
insur- ance 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.
11. 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.
12. Which of the following is an anticipated change in the relationships be-
tween consumers and providers?:Answer: Providers will face many new
service demands and consumers will have virtually unfettered access to
those services
13. What transition began as a result of the March 2010 healthcare reform
leg- islation?:Answer: A transition toward new models of health care delivery
with corresponding changes system financing and provider reimbursement.
14. Which statement is false concerning ABNs?:Answer: ABN began
establishing new requirements for managed care plans participating in the
Medicare program.
, 15. 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.
-Although ABNs can have significant financial implications for the
physician, they also
serve an important fraud and abuse compliance function.
16. What is the overall function of Medicaid?:Answer: The pay for medical
assistance for certain individuals and low-income families
17. Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined
as:Answer: Total Medical Expenses divided by Total Premiums
18. Provider service organizations (PSOs) function like health maintenance
or- ganizations (HMOs) in all of the following ways, EXCEPT:Answer: Ties
to the healthcare delivery industry rather than the insurance industry
19. Provider service organizations (PSOs) function like health
maintenance organizations (HMOs) in all of the following ways:Answer:
-Risk pooling
-Capitalization
-Network management
20. Which of the following is a service provided by a well-managed third-
party administrator (TPA)?:Answer: -Administrative
-Utilization review (UR)
questions with correct answers
1. Steps used to control costs of managed care include :Answer:
Bundled codes Capitation
Payer and Provider to agree on reasonable payment
2. 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
3. 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.
4. 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)
5. 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)
6. 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
7. 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)
8. 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
9. 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.
10. Which of the following statements regarding employer-based health
insur- ance 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.
11. 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.
12. Which of the following is an anticipated change in the relationships be-
tween consumers and providers?:Answer: Providers will face many new
service demands and consumers will have virtually unfettered access to
those services
13. What transition began as a result of the March 2010 healthcare reform
leg- islation?:Answer: A transition toward new models of health care delivery
with corresponding changes system financing and provider reimbursement.
14. Which statement is false concerning ABNs?:Answer: ABN began
establishing new requirements for managed care plans participating in the
Medicare program.
, 15. 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.
-Although ABNs can have significant financial implications for the
physician, they also
serve an important fraud and abuse compliance function.
16. What is the overall function of Medicaid?:Answer: The pay for medical
assistance for certain individuals and low-income families
17. Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined
as:Answer: Total Medical Expenses divided by Total Premiums
18. Provider service organizations (PSOs) function like health maintenance
or- ganizations (HMOs) in all of the following ways, EXCEPT:Answer: Ties
to the healthcare delivery industry rather than the insurance industry
19. Provider service organizations (PSOs) function like health
maintenance organizations (HMOs) in all of the following ways:Answer:
-Risk pooling
-Capitalization
-Network management
20. Which of the following is a service provided by a well-managed third-
party administrator (TPA)?:Answer: -Administrative
-Utilization review (UR)
