CSPR – Certified Specialist Payment Rep (HFMA)Exam
Questions with Correct Answers
100% Verified Graded A+
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 governmentsponsored 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.
Questions with Correct Answers
100% Verified Graded A+
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 governmentsponsored 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.
