CSPR - Certified Specialist Payment Rep (HFMA) Exam Questions And Answers
Steps used to control costs of managed care include: - ANS Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - ANS Inpatient admissions for the purpose of reimbursi...
CSPR
-
Certified
Specialist
Payment
Rep
(HFMA) Steps
used
to
control
costs
of
managed
care
include:
-
ANS
Bundled
codes
Capitation
Payer
and
Provider
to
agree
on
reasonable
payment
DRG
is
used
to
classify
-
ANS
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
-
ANS
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:
-
ANS
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:
-
ANS
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
-
ANS
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)
-
ANS
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:
-
ANS
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
HMO
Act
of
1973
-
ANS
The
HMO
Act
of
1973
gave
federally
qualified
HMOs
the
right
to
mandate
that
employers
offer
their
product
to
their
employees
under
certain
conditions.
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.
Which
of
the
following
statements
regarding
employer-based
health
insurance
in
the
United
States
is
true?
-
ANS
The
real
advent
of
employer-based
insurance
came
through
Blue
Cross,
which
was
started
by
hospital
associations
during
the
Depression.
The
Health
Maintenance
Organization
(HMO)
Act
of
1973
gave
qualified
HMOs
the
right
to
"mandate"
an
employer
under
certain
conditions,
meaning
employers:
-
ANS
Would
have
to
offer
HMO
plans
along
side
traditional
fee-for-service
medical
plans.
Which
of
the
following
is
an
anticipated
change
in
the
relationships
between
consumers
and
providers?
-
ANS
Providers
will
face
many
new
service
demands
and
consumers
will
have
virtually
unfettered
access
to
those
services
What
transition
began
as
a
result
of
the
March
2010
healthcare
reform
legislation?
-
ANS
A
transition
toward
new
models
of
health
care
delivery
with
corresponding
changes
system
financing
and
provider
reimbursement.
Which
statement
is
false
concerning
ABNs?
-
ANS
ABN
began
establishing
new
requirements
for
managed
care
plans
participating
in
the
Medicare
program.
Which
Statement
is
TRUE
concerning
ABNs?
-
ANS
-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.
-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
of
Medicaid?
-
ANS
The
pay
for
medical
assistance
for
certain
individuals
and
low-income
families
Medical
Cost
Ratio
(MCR)
or
Medical
Loss
Ratio
(MLR)
is
defined
as:
-
ANS
Total
Medical
Expenses
divided
by
Total
Premiums
Provider
service
organizations
(PSOs)
function
like
health
maintenance
organizations
(HMOs)
in
all
of
the
following
ways,
EXCEPT:
-
ANS
Ties
to
the
healthcare
delivery
industry
rather
than
the
insurance
industry
Provider
service
organizations
(PSOs)
function
like
health
maintenance
organizations
(HMOs)
in
all
of
the
following
ways:
-
ANS
-Risk
pooling
-Capitalization
-Network
management
Which
of
the
following
is
a
service
provided
by
a
well-managed
third-party
administrator
(TPA)?
-
ANS
-Administrative
-Utilization
review
(UR)
-Claims
processing
What
is
tiering?
-
ANS
The
ranking
or
classifying
of
one
or
more
of
the
provider
delivery
system
components
Which
option
is
a
practice
used
to
control
costs
of
managed
care?
-
ANS
-Making
advance
payment
to
providers
for
all
services
needed
to
care
for
a
member
-Combining
services
provided
and
bundling
the
associated
charges
-Agreement
between
the
payer
and
provider
on
reasonable
payment
for
each
service.
Which
option
is
a
risk
involved
in
per
diem
payments?
-
ANS
-The
risk
to
the
insurance
company
or
health
plan
-The
risk
to
the
hospital
-The
risk
when
embracing
per
diem
payments
in
complex
case
Diagnosis-related
group
(DRG)
is:
-
ANS
A
payment
category
How
is
the
term
carve-out
used
when
discussing
managed
care?
-
ANS
To
refer
to
specific
benefits
or
services
What
is
the
term
Coordination
of
Benefits
(COB)?
-
ANS
A
term
used
to
describe
how
payment
is
coordinated
for
patients
who
have
coverage
through
two
insurance
policies
Which
three
components
are
used
to
determine
the
total
RVU
value
for
a
service?
-
ANS
-Malpractice
expense
-Lowest
market
price
for
services
used
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 Studyclock. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $9.49. You're not tied to anything after your purchase.
