CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) 2024/2025
NEWEST!! ACTUAL COMPLETE 350 REAL EXAM QUESTIONS
WITH CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
/ALREADY GRADED A+
What is the purpose of Consolidated Omnibus Budget
Reconciliation Act (COBRA)
legislation? - ANSWER -To provide continuation of group
health coverage that
otherwise might be
terminated
What is one purpose of the Emergency Medical Treatment and
Active Labor Act (EMTALA)? - ANSWER -To govern when and how
a patient presenting at a hospital may be refused treatment
Steps used to control costs of managed care include: - ANSWER
-Bundled codes
Capitation
Payer and Provider to agree on reasonable
payment
What was the aim of the HMO Act of 1973? - ANSWER -To change
the system of
,health care
delivery.
To be eligible for COBRA coverage, an employee must have: -
ANSWER -Been
enrolled in an employer's health plan while working and the
health plan must
continue to be in effect for active
employees.
DRG is used to classify - ANSWER -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
Identify the various types of private health plan coverage -
ANSWER -HMO
Conventional
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.
Managed care organizations (MCO) exist primarily in four forms: -
ANSWER -Health
,Maintenance Organizations
(HMO)
Preferred Provider
Organizations (PPO)
Point of Service (POS)
Organizations
Exclusive Provider
Organizations (EPO)
Identify the various types of government‐sponsored health
coverage: - ANSWER Medicare - Government; Beneficiaries
enrolled in such plans, but, participation in these plans is
voluntary.
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)
Identify some key drivers of increasing healthcare costs - ANSWER
–Demographics
Chronic
Conditions
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
Health Maintenance Organizations (HMO) - ANSWER -
Referrals 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)
Medicare is composed of four parts: - ANSWER -Part A - provides
inpatient/hospital, hospice, and 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
Which statement is false concerning ABNs? - ANSWER -ABN
began establishing
new requirements for managed care plans participating in the
Medicare program.
Which Statement is TRUE concerning ABNs? - ANSWER --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 covered by Medicare and that he or
she will need to pay out of pocket.
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