CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS WITH EXPLANATIONS
(VERIFIED ANSWERS) A NEW UPDATED VERSION LATEST|
GUARANTEED A+
1) Steps used to control Bundled codes
costs of managed care Capitation
include: Payer and Provider to agree on reasonable
payment
2) DRG is used to classify 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 HMO
types of private health Conventional
plan coverage 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 Health Maintenance Organizations (HMO)
organizations (MCO) Preferred Provider Organizations (PPO)
exist primarily in four Point of Service (POS) Organizations
forms: Exclusive Provider Organizations (EPO)
5) Identify the various Medicare - Government; Beneficiaries enrolled
types of government‐ in such plans, but, participation in these
sponsored health plans is voluntary.
coverage: 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 Demographics
drivers of increasing Chronic Conditions
, healthcare costs 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 Referrals
Organizations (HMO) 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 Part A - provides inpatient/hospital, hospice, and
of four parts: 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 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 The real advent of employer-based insurance
statements regarding came through Blue Cross, which was started by
employer-based health hospital associations during the Depression.
insurance in the United
States is true?
11) The Health Would have to offer HMO plans along side
Maintenance traditional fee-for-service medical plans.
Organization (HMO)
Act of 1973 gave
qualified HMOs the
right to "mandate" an
employer under certain
conditions, meaning
employers:
12) Which of the following Providers will face many new service demands
is an anticipated and consumers will have virtually unfettered
change in the access to those services
relationships between
, consumers and
providers?
13) What transition began A transition toward new models of health care
as a result of the March delivery with corresponding changes system
2010 healthcare reform financing and provider reimbursement.
legislation?
14) Which statement is ABN began establishing new requirements for
false concerning managed care plans participating in the
ABNs? Medicare program.
15) Which Statement is -ABNs are not required for services that are
TRUE concerning never covered by Medicare.
ABNs? -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 The pay for medical assistance for certain
function of Medicaid? individuals and low-income families
17) Medical Cost Ratio Total Medical Expenses divided by Total
(MCR) or Medical Loss Premiums
Ratio (MLR) is defined
as:
18) Provider service Ties to the healthcare delivery industry rather
organizations (PSOs) than the insurance industry
function like health
maintenance
organizations (HMOs)
in all of the following
ways, EXCEPT:
19) Provider service -Risk pooling
organizations (PSOs) -Capitalization
function like health -Network management
maintenance
organizations (HMOs)
in all of the following
ways:
20) Which of the following -Administrative
is a service provided by -Utilization review (UR)
a well-managed third- -Claims processing
party administrator
(TPA)?
21) What is tiering? The ranking or classifying of one or more of the
provider delivery system components
QUESTIONS AND CORRECT DETAILED ANSWERS WITH EXPLANATIONS
(VERIFIED ANSWERS) A NEW UPDATED VERSION LATEST|
GUARANTEED A+
1) Steps used to control Bundled codes
costs of managed care Capitation
include: Payer and Provider to agree on reasonable
payment
2) DRG is used to classify 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 HMO
types of private health Conventional
plan coverage 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 Health Maintenance Organizations (HMO)
organizations (MCO) Preferred Provider Organizations (PPO)
exist primarily in four Point of Service (POS) Organizations
forms: Exclusive Provider Organizations (EPO)
5) Identify the various Medicare - Government; Beneficiaries enrolled
types of government‐ in such plans, but, participation in these
sponsored health plans is voluntary.
coverage: 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 Demographics
drivers of increasing Chronic Conditions
, healthcare costs 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 Referrals
Organizations (HMO) 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 Part A - provides inpatient/hospital, hospice, and
of four parts: 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 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 The real advent of employer-based insurance
statements regarding came through Blue Cross, which was started by
employer-based health hospital associations during the Depression.
insurance in the United
States is true?
11) The Health Would have to offer HMO plans along side
Maintenance traditional fee-for-service medical plans.
Organization (HMO)
Act of 1973 gave
qualified HMOs the
right to "mandate" an
employer under certain
conditions, meaning
employers:
12) Which of the following Providers will face many new service demands
is an anticipated and consumers will have virtually unfettered
change in the access to those services
relationships between
, consumers and
providers?
13) What transition began A transition toward new models of health care
as a result of the March delivery with corresponding changes system
2010 healthcare reform financing and provider reimbursement.
legislation?
14) Which statement is ABN began establishing new requirements for
false concerning managed care plans participating in the
ABNs? Medicare program.
15) Which Statement is -ABNs are not required for services that are
TRUE concerning never covered by Medicare.
ABNs? -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 The pay for medical assistance for certain
function of Medicaid? individuals and low-income families
17) Medical Cost Ratio Total Medical Expenses divided by Total
(MCR) or Medical Loss Premiums
Ratio (MLR) is defined
as:
18) Provider service Ties to the healthcare delivery industry rather
organizations (PSOs) than the insurance industry
function like health
maintenance
organizations (HMOs)
in all of the following
ways, EXCEPT:
19) Provider service -Risk pooling
organizations (PSOs) -Capitalization
function like health -Network management
maintenance
organizations (HMOs)
in all of the following
ways:
20) Which of the following -Administrative
is a service provided by -Utilization review (UR)
a well-managed third- -Claims processing
party administrator
(TPA)?
21) What is tiering? The ranking or classifying of one or more of the
provider delivery system components
