CSPR Certified Specialist Payment Rep (HFMA)
Exam | Verified Questions and Correct Answers
| A+ Graded
1. Steps used t0 c0ntr0l c0sts 0f managed care include
Answer> Bundled c0des Capitati0n
Payer and Pr0vider t0 agree 0n reas0nable payment
2. DRG is used t0 classify
Answer> Inpatient admissi0ns f0r the purp0se 0f reimbursing h0spitals f0r each case in a
given categ0ry w/a neg0tiated fixed fee, regardless 0f the actual c0sts incurred
3. Identify the vari0us types 0f private health plan c0verage
Answer> HM0 C0nventi0nal
PP0 and P0S
HDHP/S0 plans - high-deductible health plans with a savings 0pti0n; Private - Include higher
patient 0ut-0f-p0cket expenditures f0r treatments that can serve t0 reduce utilizati0n/c0sts.
4. Managed care 0rganizati0ns (MC0) exist primarily in f0ur f0rms
Answer> Health Maintenance 0rganizati0ns (HM0)
Preferred Pr0vider 0rganizati0ns (PP0) P0int 0f
Service (P0S) 0rganizati0ns Exclusive Pr0vider
,0rganizati0ns (EP0)
5. Identify the vari0us types 0f g0vernmentsp0ns0red health c0verage
Answer> - Medicare - G0vernment; Beneficiaries enr0lled in such plans, but, participati0n
in these
plansisv0luntary.
Medicaid
Medicaid Managed Care - Medicaid beneficiaries are required t0 select and enr0ll in a
managed care plan.
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
6. Identify s0me key drivers 0f increasing healthcare c0sts
Answer> Dem0graphics Chr0nic C0nditi0ns
Pr0vider payment systems - Pr0vider payment systems that are designed t0 reward v0lume
rather than quality, 0utc0mes, and preventi0n
C0nsumer Percepti0ns
Health Plan pressure
PhysicianRelati0nships
Supply Chain
7. Health Maintenance 0rganizati0ns (HM0)
,Answer> Referrals PCP
Patients must use an in-netw0rk pr0vider f0r their services t0 be c0vered. Reimbursement -
maj0rity 0f services 0ffered are reimbursed thr0ugh capitati0n payments (PMPM)
8. Medicare is c0mp0sed 0f f0ur parts
Answer> Part A - pr0vides inpatient/h0spital, h0spice, and skilled nursing c0verage
Part B - pr0vides 0utpatient/medical c0verage
Part C - an alternative way t0 receive y0ur Medicare benefits (kn0wn as Medicare Advantage)
Part D - prescripti0n drug c0verage
9. HM0 Act 0f 1973
Answer> The HM0 Act 0f 1973 gave federally qualified HM0s the right t0 mandate that
empl0yers 0ffer their pr0duct t0 their empl0yees under certain c0nditi0ns. Mandating an
empl0yer meant that empl0yers wh0 had 25 0r m0re empl0yees and were f0r pr0fit
c0mpanies were required t0 make a dual ch0ice available t0 their empl0yees.
10. Which 0f the f0ll0wing statements regarding empl0yer-based health insur- ance in the
United States is true?
Answer> The real advent 0f empl0yer-based insurance came thr0ugh Blue Cr0ss, which was
started by h0spital ass0ciati0ns during the Depressi0n.
11. The Health Maintenance 0rganizati0n (HM0) Act 0f 1973 gave qualified HM0s the right
, t0 "mandate" an empl0yer under certain c0nditi0ns, meaning empl0yers
Answer> W0uld have t0 0ffer HM0 plans al0ng side traditi0nal fee-f0r-service medical plans.
12. Which 0f the f0ll0wing is an anticipated change in the relati0nships be- tween
c0nsumersand pr0viders?
Answer> Pr0viders willface many new service demands and c0nsumers will have virtually
unfettered access t0 th0se services
13. What transiti0n began as a result 0f the March 2010 healthcare ref0rm leg- islati0n?
Answer> A transiti0n t0ward new m0dels 0f health care delivery with c0rresp0nding changes
system financing and pr0vider reimbursement.
14. Which statement is false c0ncerning ABNs?
Answer> ABN began establishing new requirements f0r managed care plans participating
in the Medicare pr0gram.
15. Which Statement isTRUE c0ncerning ABNs?
Answer> -ABNs are n0t required f0r services that are never c0vered by Medicare.
-An ABN f0rm n0tifies the patient bef0re he 0r she receives the service that it may n0t be
c0vered by Medicare and that he 0r she will need t0 pay 0ut 0f p0cket.
-Alth0ugh ABNs can have significant financial implicati0ns f0r the physician, they als0
serve an imp0rtant fraud and abuse c0mpliance functi0n.
Exam | Verified Questions and Correct Answers
| A+ Graded
1. Steps used t0 c0ntr0l c0sts 0f managed care include
Answer> Bundled c0des Capitati0n
Payer and Pr0vider t0 agree 0n reas0nable payment
2. DRG is used t0 classify
Answer> Inpatient admissi0ns f0r the purp0se 0f reimbursing h0spitals f0r each case in a
given categ0ry w/a neg0tiated fixed fee, regardless 0f the actual c0sts incurred
3. Identify the vari0us types 0f private health plan c0verage
Answer> HM0 C0nventi0nal
PP0 and P0S
HDHP/S0 plans - high-deductible health plans with a savings 0pti0n; Private - Include higher
patient 0ut-0f-p0cket expenditures f0r treatments that can serve t0 reduce utilizati0n/c0sts.
4. Managed care 0rganizati0ns (MC0) exist primarily in f0ur f0rms
Answer> Health Maintenance 0rganizati0ns (HM0)
Preferred Pr0vider 0rganizati0ns (PP0) P0int 0f
Service (P0S) 0rganizati0ns Exclusive Pr0vider
,0rganizati0ns (EP0)
5. Identify the vari0us types 0f g0vernmentsp0ns0red health c0verage
Answer> - Medicare - G0vernment; Beneficiaries enr0lled in such plans, but, participati0n
in these
plansisv0luntary.
Medicaid
Medicaid Managed Care - Medicaid beneficiaries are required t0 select and enr0ll in a
managed care plan.
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
6. Identify s0me key drivers 0f increasing healthcare c0sts
Answer> Dem0graphics Chr0nic C0nditi0ns
Pr0vider payment systems - Pr0vider payment systems that are designed t0 reward v0lume
rather than quality, 0utc0mes, and preventi0n
C0nsumer Percepti0ns
Health Plan pressure
PhysicianRelati0nships
Supply Chain
7. Health Maintenance 0rganizati0ns (HM0)
,Answer> Referrals PCP
Patients must use an in-netw0rk pr0vider f0r their services t0 be c0vered. Reimbursement -
maj0rity 0f services 0ffered are reimbursed thr0ugh capitati0n payments (PMPM)
8. Medicare is c0mp0sed 0f f0ur parts
Answer> Part A - pr0vides inpatient/h0spital, h0spice, and skilled nursing c0verage
Part B - pr0vides 0utpatient/medical c0verage
Part C - an alternative way t0 receive y0ur Medicare benefits (kn0wn as Medicare Advantage)
Part D - prescripti0n drug c0verage
9. HM0 Act 0f 1973
Answer> The HM0 Act 0f 1973 gave federally qualified HM0s the right t0 mandate that
empl0yers 0ffer their pr0duct t0 their empl0yees under certain c0nditi0ns. Mandating an
empl0yer meant that empl0yers wh0 had 25 0r m0re empl0yees and were f0r pr0fit
c0mpanies were required t0 make a dual ch0ice available t0 their empl0yees.
10. Which 0f the f0ll0wing statements regarding empl0yer-based health insur- ance in the
United States is true?
Answer> The real advent 0f empl0yer-based insurance came thr0ugh Blue Cr0ss, which was
started by h0spital ass0ciati0ns during the Depressi0n.
11. The Health Maintenance 0rganizati0n (HM0) Act 0f 1973 gave qualified HM0s the right
, t0 "mandate" an empl0yer under certain c0nditi0ns, meaning empl0yers
Answer> W0uld have t0 0ffer HM0 plans al0ng side traditi0nal fee-f0r-service medical plans.
12. Which 0f the f0ll0wing is an anticipated change in the relati0nships be- tween
c0nsumersand pr0viders?
Answer> Pr0viders willface many new service demands and c0nsumers will have virtually
unfettered access t0 th0se services
13. What transiti0n began as a result 0f the March 2010 healthcare ref0rm leg- islati0n?
Answer> A transiti0n t0ward new m0dels 0f health care delivery with c0rresp0nding changes
system financing and pr0vider reimbursement.
14. Which statement is false c0ncerning ABNs?
Answer> ABN began establishing new requirements f0r managed care plans participating
in the Medicare pr0gram.
15. Which Statement isTRUE c0ncerning ABNs?
Answer> -ABNs are n0t required f0r services that are never c0vered by Medicare.
-An ABN f0rm n0tifies the patient bef0re he 0r she receives the service that it may n0t be
c0vered by Medicare and that he 0r she will need t0 pay 0ut 0f p0cket.
-Alth0ugh ABNs can have significant financial implicati0ns f0r the physician, they als0
serve an imp0rtant fraud and abuse c0mpliance functi0n.
