CSBI HFMA CERTIFIED SPECIALIST
BUSINESS INTELLIGENCE 2026
ANALYTICS SCRIPT SOLVED
QUESTIONS VERIFIED ANSWERS A+
◉ DRG is used to classify
Answer: 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
Answer: 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:
Answer: 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:
,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)
◉ 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
◉ 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)
,◉ Medicare is composed of four parts:
Answer: 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
Answer: 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?
Answer: 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:
, Answer: 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?
Answer: 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?
Answer: A transition toward new models of health care delivery with
corresponding changes system financing and provider reimbursement.
◉ Which statement is false concerning ABNs?
Answer: ABN began establishing new requirements for managed care
plans participating in the Medicare program.
◉ Which Statement is TRUE concerning ABNs?
Answer: -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.
BUSINESS INTELLIGENCE 2026
ANALYTICS SCRIPT SOLVED
QUESTIONS VERIFIED ANSWERS A+
◉ DRG is used to classify
Answer: 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
Answer: 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:
Answer: 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:
,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)
◉ 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
◉ 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)
,◉ Medicare is composed of four parts:
Answer: 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
Answer: 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?
Answer: 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:
, Answer: 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?
Answer: 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?
Answer: A transition toward new models of health care delivery with
corresponding changes system financing and provider reimbursement.
◉ Which statement is false concerning ABNs?
Answer: ABN began establishing new requirements for managed care
plans participating in the Medicare program.
◉ Which Statement is TRUE concerning ABNs?
Answer: -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.
