CSPR - Certified Specialist Payment Rep Exam Study Questions with Correct Answers

CSPR - Certified Specialist Payment Rep Exam Study Questions with Correct Answers 1. What type of provider authorization is applied in emergency cases, where prior authorization is impossible? - ANSWER Concurrent 2. What is utilization management (UM)? - ANSWER A tool to control the costs of providing healthcare services to enrollees 3. Which of the following statements is true about disease management (DM)? - ANSWER DM programs encourage patients to assume some control over their disease state 4. What is the function of catastrophic case management (CM)? - ANSWER It is used to manage diseases in patients with very high costs of care. 5. What is demand management? - ANSWER A coordinated effort by the MCO, employers, and providers to control the utilization of medical services and resources 6. All of the following are effective contract evaluation criteria, EXCEPT: - ANSWER Detailed contract performance assessments 7. All of the following are effective contract evaluation criteria: - ANSWER - General payer or provider criteria -Reimbursement levels and parameters -Provider costs and responsibilities 8. The following are tools for optimizing contract performance, EXCEPT: - ANSWER Contract language 9. The following are tools for optimizing contract performance: - ANSWER - Financial and volume analysis models. -Managed care contract dashboard. -Detailed contract performance assessments. 10.What is the overall function of Medicaid? - ANSWER The pay for medical assistance for certain individuals and low-income families 11.Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - ANSWER Total Medical Expenses divided by Total Premiums 12.Provider service organizations (PSOs) function like health maintenance organizations (HMOs) in all of the following ways, EXCEPT: - ANSWER Ties to the healthcare delivery industry rather than the insurance industry 13.Provider service organizations (PSOs) function like health maintenance organizations (HMOs) in all of the following ways: - ANSWER -Risk pooling -Capitalization -Network management 14.Which of the following is a service provided by a well-managed third-party administrator (TPA)? - ANSWER -Administrative -Utilization review (UR) -Claims processing 15.What is tiering? - ANSWER The ranking or classifying of one or more of the provider delivery system components 16.Which option is a practice used to control costs of managed care? - ANSWER -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. 17.Which option is a risk involved in per diem payments? - ANSWER -The risk to the insurance company or health plan -The risk to the hospital -The risk when embracing per diem payments in complex case 18.All of the following should be analyzed prior to and/or during contract negotiations, EXCEPT: - ANSWER Historical member premiums 19.All of the following should be analyzed prior to and/or during contract negotiations: - ANSWER -Member volumes by product type -Historical reimbursement levels by product type -Historical claims payment and/or submission problems Managed care organizations (MCO) exist primarily in four forms: - ANSWER Health Maintenance Organizations (HMO) Preferred Provider Organizations (PPO) Point of Service (POS) Organizations Exclusive Provider Organizations (EPO) 20.Identify the various types of government‐sponsored health coverage: - ANSWER 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) 21.Identify some key drivers of increasing healthcare costs - ANSWER 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 22.Health Maintenance Organizations (HMO) - ANSWER 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)