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CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) QUESTIONS WITH CORRECT ANSWERS
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CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) QUESTIONS WITH CORRECT ANSWERS
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CSPR - CERTIFIED SPECIALISTPAYMENT REP (HFMA) QUESTIONS
WITH CORRECT ANSWERS
Stepssusedstoscontrolscostssofsmanagedscaresinclude:s-sBundledscodes
Capitations
PayersandsProviderstosagreesonsreasonablespayment
DRGsissusedstosclassifys-
sInpatientsadmissionssforsthespurposesofsreimbursingshospitalssforseachscasesinsasgivensc
ategorysw/asnegotiatedsfixedsfee,sregardlesssofsthesactualscostssincurred
Identifysthesvariousstypessofsprivateshealthsplanscoverages-sHMO
Conventional
PPOsandsPOS
HDHP/SOsplanss-shigh-deductibleshealthsplansswithsassavingssoption;sPrivates-
sIncludeshigherspatientsout-of-
pocketsexpendituressforstreatmentssthatscansservestosreducesutilization/costs.
Managedscaresorganizationss(MCO)sexistsprimarilysinsfoursforms:s-
sHealthsMaintenancesOrganizationss(HMO)
PreferredsProvidersOrganizationss(PPO)
PointsofsServices(POS)sOrganizations
ExclusivesProvidersOrganizationss(EPO)
Identifysthesvariousstypessofsgovernment‐sponsoredshealthscoverage:s-sMedicares-
sGovernment;sBeneficiariessenrolledsinssuchsplans,sbut,sparticipationsinsthese
planssissvoluntary.
Medicaid
MedicaidsManagedsCares-
sMedicaidsbeneficiariessaresrequiredstosselectsandsenrollsinsasmanagedscaresplan.
MedicaresManagedsCares(a.k.a.sMedicaresAdvantagesPlans)
Identifyssomeskeysdriverssofsincreasingshealthcarescostss-sDemographics
ChronicsConditions
,Providerspaymentssystemss-
sProviderspaymentssystemssthatsaresdesignedstosrewardsvolumesrathersthansquality,soutco
mes,sandsprevention
ConsumersPerceptions
HealthsPlanspressure
PhysiciansRelationships
SupplysChain
HealthsMaintenancesOrganizationss(HMO)s-sReferrals
PCP
Patientssmustsusesansin-networksprovidersforstheirsservicesstosbescovered.
Reimbursements-
smajoritysofsservicessofferedsaresreimbursedsthroughscapitationspaymentss(PMPM)
Medicaresisscomposedsofsfoursparts:s-sPartsAs-sprovidessinpatient/
hospital,shospice,sandsskilledsnursingscoverage
PartsBs-sprovidessoutpatient/medicalscoverage
PartsCs-sansalternativeswaystosreceivesyoursMedicaresbenefitss(knownsassMedicare
Advantage)
PartsDs-sprescriptionsdrugscoverage
HMOsActsofs1973s-
sThesHMOsActsofs1973sgavesfederallysqualifiedsHMOssthesrightstosmandatesthatsemployer
ssofferstheirsproductstostheirsemployeessunderscertainsconditions.sMandatingsansemployers
meantsthatsemployersswhoshads25sorsmoresemployeessandsweresfor‐
profitscompaniessweresrequiredstosmakesasdualschoicesavailablestostheirsemployees.
Whichsofsthesfollowingsstatementssregardingsemployer-
basedshealthsinsurancesinsthesUnitedsStatessisstrue?s-sThesrealsadventsofsemployer-
basedsinsurancescamesthroughsBluesCross,swhichswassstartedsbyshospitalsassociationssd
uringsthesDepression.
ThesHealthsMaintenancesOrganizations(HMO)sActsofs1973sgavesqualifiedsHMOssthesrights
tos"mandate"sansemployersunderscertainsconditions,smeaningsemployers:s-
sWouldshavestosoffersHMOsplanssalongssidestraditionalsfee-for-servicesmedicalsplans.
Whichsofsthesfollowingsissansanticipatedschangesinsthesrelationshipssbetweensconsumerss
andsproviders?s-
sProvidersswillsfacesmanysnewsservicesdemandssandsconsumersswillshavesvirtuallysunfette
redsaccessstosthosesservices
WhatstransitionsbegansassasresultsofsthesMarchs2010shealthcaresreformslegislation?s-
sAstransitionstowardsnewsmodelssofshealthscaresdeliveryswithscorrespondingschangesssyst
emsfinancingsandsprovidersreimbursement.
, WhichsstatementsissfalsesconcerningsABNs?s-
sABNsbegansestablishingsnewsrequirementssforsmanagedscaresplanssparticipatingsinsthes
Medicaresprogram.
WhichsStatementsissTRUEsconcerningsABNs?s-s-
ABNssaresnotsrequiredsforsservicessthatsaresneverscoveredsbysMedicare.
-AnsABNsformsnotifiessthespatientsbeforeshesorsshesreceivessthesservicesthatsitsmaysnotsbe
coveredsbysMedicaresandsthatshesorssheswillsneedstospaysoutsofspocket.
-AlthoughsABNsscanshavessignificantsfinancialsimplicationssforsthesphysician,stheysalso
servesansimportantsfraudsandsabusescompliancesfunction.
WhatsissthesoverallsfunctionsofsMedicaid?s-
sThespaysforsmedicalsassistancesforscertainsindividualssandslow-incomesfamilies
MedicalsCostsRatios(MCR)sorsMedicalsLosssRatios(MLR)sissdefinedsas:s-
sTotalsMedicalsExpensessdividedsbysTotalsPremiums
Providersservicesorganizationss(PSOs)sfunctionslikeshealthsmaintenancesorganizationss(H
MOs)sinsallsofsthesfollowingsways,sEXCEPT:s-
sTiesstostheshealthcaresdeliverysindustrysrathersthansthesinsurancesindustry
Providersservicesorganizationss(PSOs)sfunctionslikeshealthsmaintenancesorganizationss(H
MOs)sinsallsofsthesfollowingsways:s-s-Riskspooling
-Capitalization
-Networksmanagement
Whichsofsthesfollowingsissasservicesprovidedsbysaswell-managedsthird-
partysadministrators(TPA)?s-s-Administrative
-Utilizationsreviews(UR)s
-Claimssprocessing
Whatsisstiering?s-
sThesrankingsorsclassifyingsofsonesorsmoresofsthesprovidersdeliveryssystemscomponents
Whichsoptionsissaspracticesusedstoscontrolscostssofsmanagedscare?s-s-
Makingsadvancespaymentstosproviderssforsallsservicessneededstoscaresforsasmember
-Combiningsservicessprovidedsandsbundlingsthesassociatedscharges
-Agreementsbetweensthespayersandsprovidersonsreasonablespaymentsforseachsservice.
Whichsoptionsissasrisksinvolvedsinspersdiemspayments?s-s-
Thesriskstosthesinsurancescompanysorshealthsplan
-Thesriskstostheshospital
-Thesriskswhensembracingspersdiemspaymentssinscomplexscase
Diagnosis-relatedsgroups(DRG)sis:s-sAspaymentscategory
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