CSPR - Certified Specialist Payment Rep (HFMA) Latest Update 2024 -2025 125 Questions and 100% Verified Correct Answers Guaranteed A+ A fixed payment amount based upon the number of members assigned to a provider, and does not vary based upon the number of services rendered, is known as: - CORRECT ANSWER: Capitation According to MedPAC, which option is a benefit or undesirable consequence of bundling payments? - CORRECT ANSWER: -It allows Medicare to pay a set fee per hospitalization episode. -It would provide the potential to improve efficiency and quality -It would lead to underutilization of services Advanced Beneficiary Notice (ABN): Potential Service Denials - CORRECT ANSWER: Although typically covered by Medicare, the following services are likely to be denied for lack of medical necessity under the circumstances described below: -Lab Tests - Lab tests (for example, complete blood count) when the diagnosis code does not support Medicare's definition of medical necessity. -Pap Smear - A screening Pap smear and pelvic exam given more often than every two years, unless the beneficiary is in a category for which annual exams are covered -Screening Fecal Occult Blood Test - A screening fecal occult blood test given more often than annually or if the beneficiary is younger than 50 years -Screening flexible sigmoidoscopy - A screening flexible sigmoidoscopy given more often than every four years or if the beneficiary is younger than 45 years -Prostate Cancer Screening - A prostate cancer screening test given more often than annually or if the beneficiary is younger than 50 years -Tetanus vaccine - A tetanus vaccine given prophylactically (as compared to one given because the patient stepped on a rusty nail) -Local Medical Review Policy (LMRP) - Any service that does not meet the coverage criteria established in Local Medical Review Policy (LMRP). Some Medicare carriers have established specific coverage criteria. For example, some carriers have established LMRPs for common office procedures such as removal of benign skin lesions. You can find LMRPs through the website of your local Medicare carrier. Aligning incentives has come to mean _________. - CORRECT ANSWER: The appropriate addition of some risk in the exchange of health care to a patient for some form of remuneration. All of the following are effective contract evaluation criteria, EXCEPT: - CORRECT ANSWER: Detailed contract performance assessments All of the following are effective contract evaluation criteria: - CORRECT ANSWER: -
General payer or provider criteria -Reimbursement levels and parameters -Provider costs and responsibilities All of the following are responsibilities of a provider organization's Board of Directors, EXCEPT: - CORRECT ANSWER: Implementation issues All of the following are responsibilities of a provider organization's Board of Directors: - CORRECT ANSWER: -Fiduciary matters -Legal affairs -Policy matters All of the following should be analyzed prior to and/or during contract negotiations, EXCEPT: - CORRECT ANSWER: Historical member premiums All of the following should be analyzed prior to and/or during contract negotiations: - CORRECT ANSWER: -Member volumes by product type -Historical reimbursement levels by product type -Historical claims payment and/or submission problems As the healthcare industry moves to control growth in medical spending, what initiative can help hospitals maintain their margins? - CORRECT ANSWER: Contract standardization As the healthcare industry moves to control growth in medical spending, what initiative can NOT help hospitals maintain their margins? - CORRECT ANSWER: -Pay-for-
performance programs -Health savings accounts -Price transparency Base MS -DRG payment, hospitals receive adjusted reimbursement for the following categories of costs: - CORRECT ANSWER: -Cost Outliers - Cost Outliers are defined as cases involving atypical lengths of stay or atypical cost -Transfer Policy - Reduced payments for short stay patients -Direct/Indirect Medical Education - Direct and indirect costs of patient care associated with operating approved graduate medical education program. Reimbursement is based on the ratio of interns and residents to hospital beds (IRB). -Disportionate Share - Hospitals that serve a significant indigent population may qualify as a disproportionate share hospital and receive an additional amount determined by a formula based on the percentage of Supplemental Security Income (SSI) and Medicaid patients. Distribution of funds is based on the hospital's share of national uncompensated care for all Medicare DSH hospitals. -End-Stage Renal Disease - Payment is calculated using a formula that incorporates the weekly cost of dialysis (composite rate). Catastrophic Case Management - CORRECT ANSWER: used to manage diseases associated with very high costs of care. Clear implications for CDHP consumers include the following: - CORRECT ANSWER: -
More Financial Burden ‐CDHPs shift greater premium percentages to the consumer and have higher copayments, deductibles, and stop ‐loss thresholds than traditional managed care plans. -Accountability for Healthcare Use ‐Some plans offer members points for life style behaviors that support better health (points for nonsmokers, exercise, etc.). -Shopping for Health Care ‐Consumers are incentivized to research the most appropriate healthcare provider. Many payer websites now have financial calculators to help consumers determine what their cost will be under their benefit plan. -Record Keeping - Consumers may be required to track claims and payments to account for out ‐of‐pocket costs, copayments, and deductible thresholds. In addition, the HRA component and stop ‐loss coverage add further complexity. Many of the CDHPs have tools to help members track claims, but this may be a burden for consumers to bear. CMS is responsible for: - CORRECT ANSWER: -clear policy on eligibility for CMS programs, coverage and reimbursement of healthcare services, standards for providers, and program administration. -Administration of comprehensive agreements with contractors and states; the performance standards that must be met in their administration, and the programmatic results that are to be achieved. -Monitoring the performance of contractors and states Consumer benefits for CDHPs include the following: - CORRECT ANSWER: -Coverage ‐ CDHPs allow consumers to purchase coverage for things not typically covered by HMOs or other benefit plans (such as laser eye surgery and acupuncture). -Access ‐ There are fewer barriers to physician access (such as referral mechanisms and preauthorization requirements) in CDHPs. -Choice ‐ CDHPs represent an additional benefit plan choice that adds to the common dual‐choice (HMO, PPO) offerings of employers. Diagnosis -related group (DRG) is: - CORRECT ANSWER: A payment category Direct contracting - CORRECT ANSWER: defined as single ‐employer or multi ‐employer healthcare alliances that contract directly with providers for healthcare services.
General payer or provider criteria -Reimbursement levels and parameters -Provider costs and responsibilities All of the following are responsibilities of a provider organization's Board of Directors, EXCEPT: - CORRECT ANSWER: Implementation issues All of the following are responsibilities of a provider organization's Board of Directors: - CORRECT ANSWER: -Fiduciary matters -Legal affairs -Policy matters All of the following should be analyzed prior to and/or during contract negotiations, EXCEPT: - CORRECT ANSWER: Historical member premiums All of the following should be analyzed prior to and/or during contract negotiations: - CORRECT ANSWER: -Member volumes by product type -Historical reimbursement levels by product type -Historical claims payment and/or submission problems As the healthcare industry moves to control growth in medical spending, what initiative can help hospitals maintain their margins? - CORRECT ANSWER: Contract standardization As the healthcare industry moves to control growth in medical spending, what initiative can NOT help hospitals maintain their margins? - CORRECT ANSWER: -Pay-for-
performance programs -Health savings accounts -Price transparency Base MS -DRG payment, hospitals receive adjusted reimbursement for the following categories of costs: - CORRECT ANSWER: -Cost Outliers - Cost Outliers are defined as cases involving atypical lengths of stay or atypical cost -Transfer Policy - Reduced payments for short stay patients -Direct/Indirect Medical Education - Direct and indirect costs of patient care associated with operating approved graduate medical education program. Reimbursement is based on the ratio of interns and residents to hospital beds (IRB). -Disportionate Share - Hospitals that serve a significant indigent population may qualify as a disproportionate share hospital and receive an additional amount determined by a formula based on the percentage of Supplemental Security Income (SSI) and Medicaid patients. Distribution of funds is based on the hospital's share of national uncompensated care for all Medicare DSH hospitals. -End-Stage Renal Disease - Payment is calculated using a formula that incorporates the weekly cost of dialysis (composite rate). Catastrophic Case Management - CORRECT ANSWER: used to manage diseases associated with very high costs of care. Clear implications for CDHP consumers include the following: - CORRECT ANSWER: -
More Financial Burden ‐CDHPs shift greater premium percentages to the consumer and have higher copayments, deductibles, and stop ‐loss thresholds than traditional managed care plans. -Accountability for Healthcare Use ‐Some plans offer members points for life style behaviors that support better health (points for nonsmokers, exercise, etc.). -Shopping for Health Care ‐Consumers are incentivized to research the most appropriate healthcare provider. Many payer websites now have financial calculators to help consumers determine what their cost will be under their benefit plan. -Record Keeping - Consumers may be required to track claims and payments to account for out ‐of‐pocket costs, copayments, and deductible thresholds. In addition, the HRA component and stop ‐loss coverage add further complexity. Many of the CDHPs have tools to help members track claims, but this may be a burden for consumers to bear. CMS is responsible for: - CORRECT ANSWER: -clear policy on eligibility for CMS programs, coverage and reimbursement of healthcare services, standards for providers, and program administration. -Administration of comprehensive agreements with contractors and states; the performance standards that must be met in their administration, and the programmatic results that are to be achieved. -Monitoring the performance of contractors and states Consumer benefits for CDHPs include the following: - CORRECT ANSWER: -Coverage ‐ CDHPs allow consumers to purchase coverage for things not typically covered by HMOs or other benefit plans (such as laser eye surgery and acupuncture). -Access ‐ There are fewer barriers to physician access (such as referral mechanisms and preauthorization requirements) in CDHPs. -Choice ‐ CDHPs represent an additional benefit plan choice that adds to the common dual‐choice (HMO, PPO) offerings of employers. Diagnosis -related group (DRG) is: - CORRECT ANSWER: A payment category Direct contracting - CORRECT ANSWER: defined as single ‐employer or multi ‐employer healthcare alliances that contract directly with providers for healthcare services.
