CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) EXAM WITH
ANSWERS GRADED A+
1. Steps used to control
costs of managed care
include:
Bundled codes
Capitation
Payer and Provider to agree on reasonable pay-
ment
2. DRG is used to classify Inpatient admissions for the purpose of reimburs-
ing ...
CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) EXAM WITH
ANSWERS GRADED A+
1. Steps used to control Bundled codes
costs of managed care Capitation
include: Payer and Provider to agree on reasonable pay-
ment
2. DRG is used to classify Inpatient admissions for the purpose of reimburs-
ing 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 pa-
tient out-of-pocket expenditures for treatments that
can serve to reduce utilization/costs.
4. Managed care organi- Health Maintenance Organizations (HMO)
zations (MCO) exist pri- Preferred Provider Organizations (PPO)
marily in four forms: Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
5. Identify the various Medicare - Government; Beneficiaries enrolled in
types of governmen- such plans, but, participation in these
t sponsored health covp- lans is voluntary.
erage: Medicaid
Medicaid Managed Care - Medicaid beneficiaries
are required to select and enroll in a managed care
plan.
Medicare Managed Care (a.k.a. Medicare Advan-
tage Plans)
6. Identify some key dri- Demographics
vers 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
,CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) EXAM WITH
ANSWERS GRADED A+
Health Plan pressure
Physician Relationships
Supply Chain
7. Health Maintenance Or- Referrals
ganizations (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 con-
ditions. Mandating an employer meant that em-
ployers 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 Main- Would have to offer HMO plans along side tradi-
tenance Organization tional fee-for-service medical plans.
(HMO) Act of 1973
gave qualified HMOs
the right to "mandate"
an employer under cer-
, CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) EXAM WITH
ANSWERS GRADED A+
tain conditions, mean-
ing employers:
12. Which of the follow- Providers will face many new service demands
ing is an anticipated and consumers will have virtually unfettered ac-
change in the rela- cess to those services
tionships between con-
sumers and providers?
13. What transition began A transition toward new models of health care de-
as a result of the March livery with corresponding changes system financ-
2010 healthcare reform ing and provider reimbursement.
legislation?
14. Which statement ABN began establishing new requirements for
is false concerning managed care plans participating in the Medicare
ABNs? program.
15. Which Statement is -ABNs are not required for services that are never
TRUE concerning 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 im-
plications 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 individ-
function of Medicaid? uals and low-income families
17. Medical Cost Ratio Total Medical Expenses divided by Total Premiums
(MCR) or Medical Loss
Ratio (MLR) is defined
as:
18. Provider service orga- Ties to the healthcare delivery industry rather than
nizations (PSOs) func- the insurance industry
tion like health main-
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller MERCYTRISHIA. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $10.49. You're not tied to anything after your purchase.
