CHFP Module 1 Certified Healthcare Financial
Professional (CHFP) Exam Questions and Verified
Answers.
Is a pre-determined amount that the patient pays before the insurer begins to pay for
services - ANSWER-deductible
a percentage of the insurance payment amount that is paid by the patient, along with
the amount paid by the insurer. - ANSWER-coinsurance
a flat amount that the patient pays at each time of service - ANSWER-copayment
payment also includes amounts for services that are not included in the patient's benefit
design and amounts for services balance billed by out-of-network providers. Payments
typically does not include premium sharing by the patient. - ANSWER-Out-of-pocket
payment
The amount payable out of pocket for healthcare services, which may includes
deductibles, copayments, coinsurance, amounts payable by the patient for services that
are not included in the patient's benefit design, and amounts "balance billed" by out-of-
network providers. Health insurance premiums constitute a separate category of
healthcare costs for patients, independent of healthcare utilization. - ANSWER-Cost (to
the patient)
The expense (direct and indirect) incurred to deliver healthcare services to patients. -
ANSWER-Costs (to the provider)
The amount payable to the provider (or reimbursable to the patient) for services
rendered. - ANSWER-Cost (to the health plan/insurer)
The expense related to provided health benefits (premiums or claims paid) - ANSWER-
Cost (to the employer)
The dollar amount a provider sets for services rendered before negotiating any
discounts. The charge can be different from the amount paid. - ANSWER-Charge
The total amount a provider expects to be paid by health plans/payers and patients for
healthcare services. - ANSWER-Price
An organization that negotiates or sets rates for provider services, collects revenue
through premium payments or tax dollars, processes provider claims for service, and
pays provider claims using collected premium or tax revenues. - ANSWER-Health
Plan/Payer
,An entity, organization, or individual that furnishes a healthcare service. - ANSWER-
Provider
Occurs when a healthcare provider bills a patient for charges (other than copayments,
coinsurance or any amounts that may remain on the patient's annual deductible) that
exceed the health plan's payment for a covered service. In-network providers are
contractually prohibited from balance billing health plan members, but balance billing by
out-of-network providers is common. - ANSWER-Balance Billing
In healthcare, readily available information on the price of healthcare services that,
together with other information, helps define the value of those services and enables
patients and other care purchasers to identify, compare and choose providers that offer
the desired level of value - ANSWER-Price Transparency
The quality of a healthcare service in relation to the total price paid for the service by
care purchasers. - ANSWER-Value
the flow of money between the patient, the insurer, and the provider of healthcare
services - ANSWER-Revenue Cycle
function between a healthcare facility or physician and an insurer is one of the most
important resource management challenges in today's healthcare industry. - ANSWER-
Billing and Collection
An older term used to describe payment by an insurer to a healthcare facility or
physician. This term is used because a physician or healthcare facility provider render
services to a patient and then submits claims a claim to an insurer. The healthcare
facility or physician waits for processing of that claim by the insurer, and ultimately
recieves payment, a determination of payment or a denial by the insurer. Today it is
more common to use the term payment. - ANSWER-Reimbursement
The price set by a healthcare facility or physician for their services is referred to as -
ANSWER-Charges or Billed Charges
The charges by a healthcare facility or physician represent the retail price and are
usually compiled in a price listing known as - ANSWER-Chargemaster
a charge-based payment mechanism in which a provider is paid either list price (full
charges) or a percentage of charges (full charges less a discount) for the specific
services rendered. - ANSWER-Fee-for-service
What does fee for service payment provides? - ANSWER-more units of service in order
to receive more payments.
,Why do Healthcare Facilities set Retail prices significantly above rates actually paid by
commercial insurers or the government? - ANSWER-1. Access to Contracted Payment
Rates.
-Rare not all insurers participate in provider networks that give them access to
contracted payment rates. Some auto insurers, liability insurers or companies providing
travel insurance to visitors from abroad still pay a provider's full charges.
2. Percent-of-Charge Contracts
-In markets with little competition, percent-of-charge contracts are still common. The
higher the price, the higher the percent-of-charge payment, unless the contract limits a
provider's annual price increases.
3. Outlier Provisions
-Some insurance contacts contain an outlier provision that entitles providers to an
additional payment (a lump-sum payment or a percentage of actual charges above a
threshold) for particularly sick and high-cost patients.
What is the use and benefits of Cost Based Payments? - ANSWER-The only use of this
method today is in a limited set of small, rural healthcare facilities known as critical
access hospitals. This mechanism has rarely been used for physicians. Cost-based
payment calls for the insurer to pay the healthcare provider based on the costs of
providing services, with a nominal allowance for margin.
What is the Medicare program began with a payment mechanism to healthcare facilities
that has since been nearly eliminated from the healthcare industry — - ANSWER-Cost
based Payment
Which of the following would benefit the most from a cost-based payment method? -
ANSWER-The healthcare provider
That's right! Let's understand how.
The payment mechanism is advantageous for healthcare providers, as there is a higher
likelihood that all costs will be paid, and there is no incentive to be efficient in providing
care, since costs will be reimbursed by the insurer. The rapid escalation of healthcare
costs in the U.S. after the start of cost-based payment in Medicare and Medicaid
programs led to the implementation of the Prospective Payment System (PPS) of
paying acute care healthcare providers for inpatient services in 1983 and outpatient
services in 2000. Since then, CMS has introduced prospective payment systems for
most other types of institutional healthcare providers
Cost-Based payment decreased need for providers to be efficient.
Mountainside Health Plan is evaluating its payment of hospitals in its current service
area. It is looking to reduce its costs per patient and stabilize its overall payments to
hospitals. Which of the following payment methods would be least effective for the
health plan to meet these objectives? - ANSWER-Cost-based payment
, You selected the correct answer. Cost-based payment is the least predictable model for
a health plan and has the greatest risk of increased cost because it is dependent on the
hospital's ability to manage operating costs.
The table below shows the methods ranked from most predictable to least predictable.
What are the 5 main types of prospective payments used in today's healthcare market?
- ANSWER-1. DRG healthcare provider
2. Per Procedure
3. Case rate - healthcare provider or physician
4. Per diem - healthcare provider
5. Bundled payment - healthcare provider, physicians and post-acute providers
A payment based on the patient's diagnosis is known as a - ANSWER-(DRG) Diagnosis
Related Group
What is the most widely used in payments to healthcare providers. - ANSWER-(DRG)'s
is a classification of a disease or injury into one of approximately 750 different
categories.
The amount paid is a flat rate per discharge and is adjusted based on:
Relative severity of the patient's condition
Resources used to treat the condition as determined by the DRG for that condition -
ANSWER-(DRG)
defines the increase or decrease adjustment to the payment. - ANSWER-Relative
weight
(each DRG is assigned relative weight)
The average level of severity of conditions of patients in a healthcare provider during a
specified period is known as - ANSWER-case mix index
A _________ pays a specified fee for each procedure performed on a patient in a
healthcare provider or ambulatory care facility, or by a physician. - ANSWER-Health
plan
What 2 payment approaches are used in the per-procedure payment plan? - ANSWER-
(APC) Ambulatory Payment Classification and Resource Based Relative Value Scale
(RBRVS)
What payment approach is similar to the inpatient DRG in that the amount paid is based
on the specific procedure or service provided to the patient? - ANSWER-(APC)
Ambulatory Payment Classification
Professional (CHFP) Exam Questions and Verified
Answers.
Is a pre-determined amount that the patient pays before the insurer begins to pay for
services - ANSWER-deductible
a percentage of the insurance payment amount that is paid by the patient, along with
the amount paid by the insurer. - ANSWER-coinsurance
a flat amount that the patient pays at each time of service - ANSWER-copayment
payment also includes amounts for services that are not included in the patient's benefit
design and amounts for services balance billed by out-of-network providers. Payments
typically does not include premium sharing by the patient. - ANSWER-Out-of-pocket
payment
The amount payable out of pocket for healthcare services, which may includes
deductibles, copayments, coinsurance, amounts payable by the patient for services that
are not included in the patient's benefit design, and amounts "balance billed" by out-of-
network providers. Health insurance premiums constitute a separate category of
healthcare costs for patients, independent of healthcare utilization. - ANSWER-Cost (to
the patient)
The expense (direct and indirect) incurred to deliver healthcare services to patients. -
ANSWER-Costs (to the provider)
The amount payable to the provider (or reimbursable to the patient) for services
rendered. - ANSWER-Cost (to the health plan/insurer)
The expense related to provided health benefits (premiums or claims paid) - ANSWER-
Cost (to the employer)
The dollar amount a provider sets for services rendered before negotiating any
discounts. The charge can be different from the amount paid. - ANSWER-Charge
The total amount a provider expects to be paid by health plans/payers and patients for
healthcare services. - ANSWER-Price
An organization that negotiates or sets rates for provider services, collects revenue
through premium payments or tax dollars, processes provider claims for service, and
pays provider claims using collected premium or tax revenues. - ANSWER-Health
Plan/Payer
,An entity, organization, or individual that furnishes a healthcare service. - ANSWER-
Provider
Occurs when a healthcare provider bills a patient for charges (other than copayments,
coinsurance or any amounts that may remain on the patient's annual deductible) that
exceed the health plan's payment for a covered service. In-network providers are
contractually prohibited from balance billing health plan members, but balance billing by
out-of-network providers is common. - ANSWER-Balance Billing
In healthcare, readily available information on the price of healthcare services that,
together with other information, helps define the value of those services and enables
patients and other care purchasers to identify, compare and choose providers that offer
the desired level of value - ANSWER-Price Transparency
The quality of a healthcare service in relation to the total price paid for the service by
care purchasers. - ANSWER-Value
the flow of money between the patient, the insurer, and the provider of healthcare
services - ANSWER-Revenue Cycle
function between a healthcare facility or physician and an insurer is one of the most
important resource management challenges in today's healthcare industry. - ANSWER-
Billing and Collection
An older term used to describe payment by an insurer to a healthcare facility or
physician. This term is used because a physician or healthcare facility provider render
services to a patient and then submits claims a claim to an insurer. The healthcare
facility or physician waits for processing of that claim by the insurer, and ultimately
recieves payment, a determination of payment or a denial by the insurer. Today it is
more common to use the term payment. - ANSWER-Reimbursement
The price set by a healthcare facility or physician for their services is referred to as -
ANSWER-Charges or Billed Charges
The charges by a healthcare facility or physician represent the retail price and are
usually compiled in a price listing known as - ANSWER-Chargemaster
a charge-based payment mechanism in which a provider is paid either list price (full
charges) or a percentage of charges (full charges less a discount) for the specific
services rendered. - ANSWER-Fee-for-service
What does fee for service payment provides? - ANSWER-more units of service in order
to receive more payments.
,Why do Healthcare Facilities set Retail prices significantly above rates actually paid by
commercial insurers or the government? - ANSWER-1. Access to Contracted Payment
Rates.
-Rare not all insurers participate in provider networks that give them access to
contracted payment rates. Some auto insurers, liability insurers or companies providing
travel insurance to visitors from abroad still pay a provider's full charges.
2. Percent-of-Charge Contracts
-In markets with little competition, percent-of-charge contracts are still common. The
higher the price, the higher the percent-of-charge payment, unless the contract limits a
provider's annual price increases.
3. Outlier Provisions
-Some insurance contacts contain an outlier provision that entitles providers to an
additional payment (a lump-sum payment or a percentage of actual charges above a
threshold) for particularly sick and high-cost patients.
What is the use and benefits of Cost Based Payments? - ANSWER-The only use of this
method today is in a limited set of small, rural healthcare facilities known as critical
access hospitals. This mechanism has rarely been used for physicians. Cost-based
payment calls for the insurer to pay the healthcare provider based on the costs of
providing services, with a nominal allowance for margin.
What is the Medicare program began with a payment mechanism to healthcare facilities
that has since been nearly eliminated from the healthcare industry — - ANSWER-Cost
based Payment
Which of the following would benefit the most from a cost-based payment method? -
ANSWER-The healthcare provider
That's right! Let's understand how.
The payment mechanism is advantageous for healthcare providers, as there is a higher
likelihood that all costs will be paid, and there is no incentive to be efficient in providing
care, since costs will be reimbursed by the insurer. The rapid escalation of healthcare
costs in the U.S. after the start of cost-based payment in Medicare and Medicaid
programs led to the implementation of the Prospective Payment System (PPS) of
paying acute care healthcare providers for inpatient services in 1983 and outpatient
services in 2000. Since then, CMS has introduced prospective payment systems for
most other types of institutional healthcare providers
Cost-Based payment decreased need for providers to be efficient.
Mountainside Health Plan is evaluating its payment of hospitals in its current service
area. It is looking to reduce its costs per patient and stabilize its overall payments to
hospitals. Which of the following payment methods would be least effective for the
health plan to meet these objectives? - ANSWER-Cost-based payment
, You selected the correct answer. Cost-based payment is the least predictable model for
a health plan and has the greatest risk of increased cost because it is dependent on the
hospital's ability to manage operating costs.
The table below shows the methods ranked from most predictable to least predictable.
What are the 5 main types of prospective payments used in today's healthcare market?
- ANSWER-1. DRG healthcare provider
2. Per Procedure
3. Case rate - healthcare provider or physician
4. Per diem - healthcare provider
5. Bundled payment - healthcare provider, physicians and post-acute providers
A payment based on the patient's diagnosis is known as a - ANSWER-(DRG) Diagnosis
Related Group
What is the most widely used in payments to healthcare providers. - ANSWER-(DRG)'s
is a classification of a disease or injury into one of approximately 750 different
categories.
The amount paid is a flat rate per discharge and is adjusted based on:
Relative severity of the patient's condition
Resources used to treat the condition as determined by the DRG for that condition -
ANSWER-(DRG)
defines the increase or decrease adjustment to the payment. - ANSWER-Relative
weight
(each DRG is assigned relative weight)
The average level of severity of conditions of patients in a healthcare provider during a
specified period is known as - ANSWER-case mix index
A _________ pays a specified fee for each procedure performed on a patient in a
healthcare provider or ambulatory care facility, or by a physician. - ANSWER-Health
plan
What 2 payment approaches are used in the per-procedure payment plan? - ANSWER-
(APC) Ambulatory Payment Classification and Resource Based Relative Value Scale
(RBRVS)
What payment approach is similar to the inpatient DRG in that the amount paid is based
on the specific procedure or service provided to the patient? - ANSWER-(APC)
Ambulatory Payment Classification
