CSPR - Certified Specialist Payment Rep
(HFMA)
1. Steps used to control costs of managed care include: - ANSWER
Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
2. 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
3. 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.
4. 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)
5. 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)
6. 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
,7. 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)
8. 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
9. 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.
10. 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.
11. 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.
12. 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
13. 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.
14. Which statement is false concerning ABNs? – ANSWER ABN began establishing new
requirements for managed care plans participating in the Medicare program.
15. 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.
16. What is the overall function of Medicaid? – ANSWER The pay for medical assistance for
certain individuals and low-income families
17. Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - ANSWER
Total Medical Expenses divided by Total Premiums
18. 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
19. Provider service organizations (PSOs) function like health maintenance organizations
(HMOs) in all of the following ways: - ANSWER
-Risk pooling
-Capitalization
-Network management
20. Which of the following is a service provided by a well-managed third-party administrator
(TPA)? – ANSWER
-Administrative
-Utilization review (UR)
-Claims processing
21. What is tiering? – ANSWER The ranking or classifying of one or more of the provider
delivery system components
22. 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.
23. 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
24. Diagnosis-related group (DRG) is: - ANSWER A payment category
25. How is the term carve-out used when discussing managed care? – ANSWER To refer to
specific benefits or services
26. What is the term Coordination of Benefits (COB)? – ANSWER A term used to describe
how payment is coordinated for patients who have coverage through two insurance
policies
(HFMA)
1. Steps used to control costs of managed care include: - ANSWER
Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
2. 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
3. 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.
4. 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)
5. 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)
6. 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
,7. 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)
8. 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
9. 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.
10. 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.
11. 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.
12. 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
13. 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.
14. Which statement is false concerning ABNs? – ANSWER ABN began establishing new
requirements for managed care plans participating in the Medicare program.
15. 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.
16. What is the overall function of Medicaid? – ANSWER The pay for medical assistance for
certain individuals and low-income families
17. Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - ANSWER
Total Medical Expenses divided by Total Premiums
18. 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
19. Provider service organizations (PSOs) function like health maintenance organizations
(HMOs) in all of the following ways: - ANSWER
-Risk pooling
-Capitalization
-Network management
20. Which of the following is a service provided by a well-managed third-party administrator
(TPA)? – ANSWER
-Administrative
-Utilization review (UR)
-Claims processing
21. What is tiering? – ANSWER The ranking or classifying of one or more of the provider
delivery system components
22. 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.
23. 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
24. Diagnosis-related group (DRG) is: - ANSWER A payment category
25. How is the term carve-out used when discussing managed care? – ANSWER To refer to
specific benefits or services
26. What is the term Coordination of Benefits (COB)? – ANSWER A term used to describe
how payment is coordinated for patients who have coverage through two insurance
policies
