Certified Specialist Payment Rep (CSPR) HFMA 2024/25 Review

Certified Specialist Payment Rep (CSPR) HFMA 2024/25 Review-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 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.