CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) 2024
ACTUAL EXAM COMPLETE QUESTIONS WITH DETAILED
VERIFIED ANSWERS/
Health Maintenance Organizations (HMO) - 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: - 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 - 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? - 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: - 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? - 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? - A
transition toward new models of health care delivery with corresponding changes
system financing and provider reimbursement.
Which statement is false concerning ABNs? - ABN began establishing new
requirements for managed care plans participating in the Medicare program.
,Which Statement is TRUE concerning ABNs? - -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.
Steps used to control costs of managed care include: - Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - 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 - 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: - 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: - 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 - 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
, What is the overall function of Medicaid? - The pay for medical assistance for certain
individuals and low-income families
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - Total Medical
Expenses divided by Total Premiums
Provider service organizations (PSOs) function like health maintenance organizations
(HMOs) in all of the following ways, EXCEPT: - 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: - -Risk pooling
-Capitalization
-Network management
Which of the following is a service provided by a well-managed third-party administrator
(TPA)? - -Administrative
-Utilization review (UR)
-Claims processing
What is tiering? - 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? - -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? - -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: - A payment category
How is the term carve-out used when discussing managed care? - To refer to specific
benefits or services
What is the term Coordination of Benefits (COB)? - 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? - -
Malpractice expense
-Lowest market price for services used
-Medicare discounts
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