Steps used to control Bundled codes
costs of managed care Capitation
include: Payer and Provider to agree on reasonable payment
Inpatient admissions for the purpose of reimbursing
hospitals for each case in a given category w/a
DRG is used to classify
negotiated fixed fee, regardless of the actual costs
incurred
HMO
Conventional
Identify the various types PPO and POS
of private health plan HDHP/SO plans - high-deductible health plans with a
coverage savings option; Private - Include higher patient out-of-
pocket expenditures for treatments that can serve to
reduce utilization/costs.
Health Maintenance Organizations (HMO)
Managed care
Preferred Provider Organizations (PPO)
organizations (MCO) exist
Point of Service (POS) Organizations
primarily in four forms:
Exclusive Provider Organizations (EPO)
,8/30/24, 5:13 PM CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) 2024 ACTUAL EXAM COMPREHENSIVE QUESTIONS WITH DET…
Medicare - Government; Beneficiaries enrolled in such
plans, but, participation in these
plans is voluntary.
Identify the various types
Medicaid
of government‐sponsored
Medicaid Managed Care - Medicaid beneficiaries are
health coverage:
required to select and enroll in a managed care plan.
Medicare Managed Care (a.k.a. Medicare Advantage
Plans)
Demographics
Chronic Conditions
Provider payment systems - Provider payment systems
Identify some key drivers that are designed to reward volume rather than quality,
of increasing healthcare outcomes, and prevention
costs Consumer Perceptions
Health Plan pressure
Physician Relationships
Supply Chain
Referrals
PCP
Health Maintenance Patients must use an in-network provider for their
Organizations (HMO) services to be covered.
Reimbursement - majority of services offered are
reimbursed through capitation payments (PMPM)
Part A - provides inpatient/hospital, hospice, and
skilled nursing coverage
Part B - provides outpatient/medical coverage
Medicare is composed of
Part C - an alternative way to receive your Medicare
four parts:
benefits (known as Medicare
Advantage)
Part D - prescription drug coverage
The HMO Act of 1973 gave federally qualified HMOs
the right to mandate that employers offer their product
to their employees under certain conditions.
HMO Act of 1973 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.
, 8/30/24, 5:13 PM CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) 2024 ACTUAL EXAM COMPREHENSIVE QUESTIONS WITH DET…
Which of the following The real advent of employer-based insurance came
statements regarding through Blue Cross, which was started by hospital
employer-based health associations during the Depression.
insurance in the United
States is true?
The Health Maintenance Would have to offer HMO plans along side traditional
Organization (HMO) Act of fee-for-service medical plans.
1973 gave qualified HMOs
the right to "mandate" an
employer under certain
conditions, meaning
employers:
Which of the following is Providers will face many new service demands and
an anticipated change in consumers will have virtually unfettered access to
the relationships between those services
consumers and providers?
What transition began as a A transition toward new models of health care delivery
result of the March 2010 with corresponding changes system financing and
healthcare reform provider reimbursement.
legislation?
ABN began establishing new requirements for
Which statement is false
managed care plans participating in the Medicare
concerning ABNs?
program.
-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
Which Statement is TRUE covered by Medicare and that he or she will need to
concerning ABNs? pay out of pocket.
-Although ABNs can have significant financial
implications for the physician, they also
serve an important fraud and abuse compliance
function.
What is the overall function The pay for medical assistance for certain individuals
of Medicaid? and low-income families
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