CSPR - Certified Specialist Payment
Rep (HFMA) with correct answers
Steps used to control costs of managed care include: - answersBundled codes
f f f f f f f f f f f
Capitation f
Payer and Provider to agree on reasonable payment
f f f f f f f
DRG is used to classify - answersInpatient admissions for the purpose of reimbursing
f f f f f f f f f f f f
hospitals for each case in a given category w/a negotiated fixed fee, regardless of the actual
f f f f f f f f f f f f f f f f
costs incurred
f f
Identify the various types of private health plan coverage - answersHMO
f f f f f f f f f f
Conventional
PPO and POS
f f
HDHP/SO plans - high-deductible health plans with a savings option; Private - Include
f f f f f f f f f f f f
higher patient out-of-pocket expenditures for treatments that can serve to reduce
f f f f f f f f f f f
utilization/costs.
f
Managed care organizations (MCO) exist primarily in four forms: - answersHealth
f f f f f f f f f f
Maintenance Organizations (HMO)
f f f
Preferred Provider Organizations (PPO) f f f
Point of Service (POS) Organizations
f f f f
Exclusive Provider Organizations (EPO) f f f
Identify the various types of government‐sponsored health coverage: - answersMedicare -
f f f f f f f f f f
Government; Beneficiaries enrolled in such plans, but, participation in these
f f f f f f f f f f
plans is voluntary.
f f
Medicaid
Medicaid Managed Care - Medicaid beneficiaries are required to select and enroll in a
f f f f f f f f f f f f f
managed care plan.
f f f
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
f f f f f f
Identify some key drivers of increasing healthcare costs - answersDemographics
f f f f f f f f f
Chronic Conditions f
Provider payment systems - Provider payment systems that are designed to reward volume
f f f f f f f f f f f f
rather than quality, outcomes, and prevention
f f f f f f
Consumer Perceptions f
Health Plan pressure f f
Physician Relationships f
Supply Chain f
,Health Maintenance Organizations (HMO) - answersReferrals
f f f f f
PCP
Patients must use an in-network provider for their services to be covered.
f f f f f f f f f f f
Reimbursement - majority of services offered are reimbursed through capitation payments f f f f f f f f f f
(PMPM)
f
Medicare is composed of four parts: - answersPart A - provides inpatient/hospital, hospice,
f f f f f f f f f f f f
and skilled nursing coverage
f f f f
Part B - provides outpatient/medical coverage
f f f f f
Part C - an alternative way to receive your Medicare benefits (known as Medicare
f f f f f f f f f f f f f
Advantage)
Part D - prescription drug coverage
f f f f f
HMO Act of 1973 - answersThe HMO Act of 1973 gave federally qualified HMOs the right to
f f f f f f f f f f f f f f f f
mandate that employers offer their product to their employees under certain conditions.
f f f f f f f f f f f f
Mandating an employer meant that employers who had 25 or more employees and were for‐
f f f f f f f f f f f f f f f
profit companies were required to make a dual choice available to their employees.
f f f f f f f f f f f f
Which of the following statements regarding employer-based health insurance in the United
f f f f f f f f f f f
States is true? - answersThe real advent of employer-based insurance came through Blue
f f f f f f f f f f f f f
Cross, which was started by hospital associations during the Depression.
f f f f f f f f f f
The Health Maintenance Organization (HMO) Act of 1973 gave qualified HMOs the right to
f f f f f f f f f f f f f
"mandate" an employer under certain conditions, meaning employers: - answersWould
f f f f f f f f f f
have to offer HMO plans along side traditional fee-for-service medical plans.
f f f f f f f f f f f
Which of the following is an anticipated change in the relationships between consumers and
f f f f f f f f f f f f f
providers? - answersProviders will face many new service demands and consumers will
f f f f f f f f f f f f
have virtually unfettered access to those services
f f f f f f f
What transition began as a result of the March 2010 healthcare reform legislation? -
f f f f f f f f f f f f f
answersA transition toward new models of health care delivery with corresponding changes
f f f f f f f f f f f f
system financing and provider reimbursement.
f f f f f
Which statement is false concerning ABNs? - answersABN began establishing new
f f f f f f f f f f
requirements for managed care plans participating in the Medicare program.
f f f f f f f f f f
Which Statement is TRUE concerning ABNs? - answers-ABNs are not required for services
f f f f f f f f f f f f
that are never covered by Medicare.
f f f f f f
-An ABN form notifies the patient before he or she receives the service that it may not be
f f f f f f f f f f f f f f f f f
covered by Medicare and that he or she will need to pay out of pocket.
f f f f f f f f f f f f f f
-Although ABNs can have significant financial implications for the physician, they also
f f f f f f f f f f f
serve an important fraud and abuse compliance function.
f f f f f f f
What is the overall function of Medicaid? - answersThe pay for medical assistance for
f f f f f f f f f f f f f
certain individuals and low-income families
f f f f f
, Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - answersTotal
f f f f f f f f f f f f f
Medical Expenses divided by Total Premiums
f f f f f f
Provider service organizations (PSOs) function like health maintenance organizations
f f f f f f f f
(HMOs) in all of the following ways, EXCEPT: - answersTies to the healthcare delivery
f f f f f f f f f f f f f f
industry rather than the insurance industry
f f f f f f
Provider service organizations (PSOs) function like health maintenance organizations
f f f f f f f f
(HMOs) in all of the following ways: - answers-Risk pooling
f f f f f f f f f f
-Capitalization
-Network management f
Which of the following is a service provided by a well-managed third-party administrator
f f f f f f f f f f f f
(TPA)? - answers-Administrative
f f f
-Utilization review (UR) f f f
-Claims processing f
What is tiering? - answersThe ranking or classifying of one or more of the provider delivery
f f f f f f f f f f f f f f f
system components
f f
Which option is a practice used to control costs of managed care? - answers-Making
f f f f f f f f f f f f f
advance payment to providers for all services needed to care for a member
f f f f f f f f f f f f f
-Combining services provided and bundling the associated charges f f f f f f f
-Agreement between the payer and provider on reasonable payment for each service.
f f f f f f f f f f f
Which option is a risk involved in per diem payments? - answers-The risk to the insurance
f f f f f f f f f f f f f f f
company or health plan
f f f f
-The risk to the hospital
f f f f
-The risk when embracing per diem payments in complex case
f f f f f f f f f
Diagnosis-related group (DRG) is: - answersA payment category f f f f f f f
How is the term carve-out used when discussing managed care? - answersTo refer to
f f f f f f f f f f f f f
specific benefits or services
f f f f
What is the term Coordination of Benefits (COB)? - answersA term used to describe how
f f f f f f f f f f f f f f
payment is coordinated for patients who have coverage through two insurance policies
f f f f f f f f f f f f
Which three components are used to determine the total RVU value for a service? -
f f f f f f f f f f f f f f
answers-Malpractice expense
f f
-Lowest market price for services used
f f f f f f
-Medicare discounts f
Rep (HFMA) with correct answers
Steps used to control costs of managed care include: - answersBundled codes
f f f f f f f f f f f
Capitation f
Payer and Provider to agree on reasonable payment
f f f f f f f
DRG is used to classify - answersInpatient admissions for the purpose of reimbursing
f f f f f f f f f f f f
hospitals for each case in a given category w/a negotiated fixed fee, regardless of the actual
f f f f f f f f f f f f f f f f
costs incurred
f f
Identify the various types of private health plan coverage - answersHMO
f f f f f f f f f f
Conventional
PPO and POS
f f
HDHP/SO plans - high-deductible health plans with a savings option; Private - Include
f f f f f f f f f f f f
higher patient out-of-pocket expenditures for treatments that can serve to reduce
f f f f f f f f f f f
utilization/costs.
f
Managed care organizations (MCO) exist primarily in four forms: - answersHealth
f f f f f f f f f f
Maintenance Organizations (HMO)
f f f
Preferred Provider Organizations (PPO) f f f
Point of Service (POS) Organizations
f f f f
Exclusive Provider Organizations (EPO) f f f
Identify the various types of government‐sponsored health coverage: - answersMedicare -
f f f f f f f f f f
Government; Beneficiaries enrolled in such plans, but, participation in these
f f f f f f f f f f
plans is voluntary.
f f
Medicaid
Medicaid Managed Care - Medicaid beneficiaries are required to select and enroll in a
f f f f f f f f f f f f f
managed care plan.
f f f
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
f f f f f f
Identify some key drivers of increasing healthcare costs - answersDemographics
f f f f f f f f f
Chronic Conditions f
Provider payment systems - Provider payment systems that are designed to reward volume
f f f f f f f f f f f f
rather than quality, outcomes, and prevention
f f f f f f
Consumer Perceptions f
Health Plan pressure f f
Physician Relationships f
Supply Chain f
,Health Maintenance Organizations (HMO) - answersReferrals
f f f f f
PCP
Patients must use an in-network provider for their services to be covered.
f f f f f f f f f f f
Reimbursement - majority of services offered are reimbursed through capitation payments f f f f f f f f f f
(PMPM)
f
Medicare is composed of four parts: - answersPart A - provides inpatient/hospital, hospice,
f f f f f f f f f f f f
and skilled nursing coverage
f f f f
Part B - provides outpatient/medical coverage
f f f f f
Part C - an alternative way to receive your Medicare benefits (known as Medicare
f f f f f f f f f f f f f
Advantage)
Part D - prescription drug coverage
f f f f f
HMO Act of 1973 - answersThe HMO Act of 1973 gave federally qualified HMOs the right to
f f f f f f f f f f f f f f f f
mandate that employers offer their product to their employees under certain conditions.
f f f f f f f f f f f f
Mandating an employer meant that employers who had 25 or more employees and were for‐
f f f f f f f f f f f f f f f
profit companies were required to make a dual choice available to their employees.
f f f f f f f f f f f f
Which of the following statements regarding employer-based health insurance in the United
f f f f f f f f f f f
States is true? - answersThe real advent of employer-based insurance came through Blue
f f f f f f f f f f f f f
Cross, which was started by hospital associations during the Depression.
f f f f f f f f f f
The Health Maintenance Organization (HMO) Act of 1973 gave qualified HMOs the right to
f f f f f f f f f f f f f
"mandate" an employer under certain conditions, meaning employers: - answersWould
f f f f f f f f f f
have to offer HMO plans along side traditional fee-for-service medical plans.
f f f f f f f f f f f
Which of the following is an anticipated change in the relationships between consumers and
f f f f f f f f f f f f f
providers? - answersProviders will face many new service demands and consumers will
f f f f f f f f f f f f
have virtually unfettered access to those services
f f f f f f f
What transition began as a result of the March 2010 healthcare reform legislation? -
f f f f f f f f f f f f f
answersA transition toward new models of health care delivery with corresponding changes
f f f f f f f f f f f f
system financing and provider reimbursement.
f f f f f
Which statement is false concerning ABNs? - answersABN began establishing new
f f f f f f f f f f
requirements for managed care plans participating in the Medicare program.
f f f f f f f f f f
Which Statement is TRUE concerning ABNs? - answers-ABNs are not required for services
f f f f f f f f f f f f
that are never covered by Medicare.
f f f f f f
-An ABN form notifies the patient before he or she receives the service that it may not be
f f f f f f f f f f f f f f f f f
covered by Medicare and that he or she will need to pay out of pocket.
f f f f f f f f f f f f f f
-Although ABNs can have significant financial implications for the physician, they also
f f f f f f f f f f f
serve an important fraud and abuse compliance function.
f f f f f f f
What is the overall function of Medicaid? - answersThe pay for medical assistance for
f f f f f f f f f f f f f
certain individuals and low-income families
f f f f f
, Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - answersTotal
f f f f f f f f f f f f f
Medical Expenses divided by Total Premiums
f f f f f f
Provider service organizations (PSOs) function like health maintenance organizations
f f f f f f f f
(HMOs) in all of the following ways, EXCEPT: - answersTies to the healthcare delivery
f f f f f f f f f f f f f f
industry rather than the insurance industry
f f f f f f
Provider service organizations (PSOs) function like health maintenance organizations
f f f f f f f f
(HMOs) in all of the following ways: - answers-Risk pooling
f f f f f f f f f f
-Capitalization
-Network management f
Which of the following is a service provided by a well-managed third-party administrator
f f f f f f f f f f f f
(TPA)? - answers-Administrative
f f f
-Utilization review (UR) f f f
-Claims processing f
What is tiering? - answersThe ranking or classifying of one or more of the provider delivery
f f f f f f f f f f f f f f f
system components
f f
Which option is a practice used to control costs of managed care? - answers-Making
f f f f f f f f f f f f f
advance payment to providers for all services needed to care for a member
f f f f f f f f f f f f f
-Combining services provided and bundling the associated charges f f f f f f f
-Agreement between the payer and provider on reasonable payment for each service.
f f f f f f f f f f f
Which option is a risk involved in per diem payments? - answers-The risk to the insurance
f f f f f f f f f f f f f f f
company or health plan
f f f f
-The risk to the hospital
f f f f
-The risk when embracing per diem payments in complex case
f f f f f f f f f
Diagnosis-related group (DRG) is: - answersA payment category f f f f f f f
How is the term carve-out used when discussing managed care? - answersTo refer to
f f f f f f f f f f f f f
specific benefits or services
f f f f
What is the term Coordination of Benefits (COB)? - answersA term used to describe how
f f f f f f f f f f f f f f
payment is coordinated for patients who have coverage through two insurance policies
f f f f f f f f f f f f
Which three components are used to determine the total RVU value for a service? -
f f f f f f f f f f f f f f
answers-Malpractice expense
f f
-Lowest market price for services used
f f f f f f
-Medicare discounts f
