CERTIFIED SPECIALIST PAYMENT REP (HFMA) EXAM
QUESTIONS WITH COMPLETE SOLUTIONS
What is an ACO? -- Answer ✔✔ A system of providers and facilities that can work in
concert to care for a given patient population
What is the purpose of the comprehension accreditation process? -- Answer ✔✔ To
evaluate an organization's compliance with the CMS COP standards and other
accreditation requirements
What was the aim of the HMO Act of 1973? -- Answer ✔✔ To change the system of
health care delivery.
HMO Act 1973 -- Answer ✔✔ -The original HMO Act was designed to create new
physician groups that would act as
prepaid practice groups (PPGs).
-HMO concept was to create a seamless integration of comprehensive care delivery
with a
financing mechanism for benefits. These benefit plans would remove most deductibles
and
copays, and also cover preventive services that were previously excluded by all insurers
Effects of the HMO Act -- Answer ✔✔ -The new law 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 by section 1310 of the HMO Act to make a dual
choice available to their employees. This meant that employees would have a choice to
select one or more HMOs or select the employer's traditional insurance plan.
,To be eligible for COBRA coverage, an employee must have: -- Answer ✔✔ Been
enrolled in an employer's health plan while working and the health plan must continue
to be in effect for active employees.
What is the purpose of Consolidated Omnibus Budget Reconciliation Act (COBRA)
legislation? -- Answer ✔✔ To provide continuation of group health coverage that
otherwise might be terminated
What is one purpose of the Emergency Medical Treatment and Active Labor Act
(EMTALA)? -- Answer ✔✔ To govern when and how a patient presenting at a hospital
may be refused treatment
What is the purpose of the URAC? -- Answer ✔✔ To promote healthcare quality
through accreditation and certification programs
Which options are a focus of the HIPAA Title II series of laws? -- Answer ✔✔ -Health
care access, portability, and renewability
-To maintain the efficiency and effectiveness of the electronic transmission of health
information.
-Health care claim professional (837P), health care claim dental (837D), and health care
claim payment/advice (835)
What was the expectation of the 2010 Patient Protection and Affordable Care Act
(PPACA)? -- Answer ✔✔ To bring coverage to millions of Americans who could not or
would not purchase health insurance
What is Managed Care? -- Answer ✔✔ 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)
Health Maintenance Organizations (HMO) -- Answer ✔✔ -Referralso 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)
Preferred Provider Organizations (PPO) -- Answer ✔✔ -No referrals
-No PCP
-Reimbursement - discounted fee-for-service based model, where providers are
contractually obligated to provide covered persons with specific services at discounted
rates. This may also be accompanied by a utilization review mechanism embedded in the
contract to manage costs over time.
Point of Service (POS) Organizations -- Answer ✔✔ -No referrals
-PCP
-Combine features of both an HMO and PPO
-A covered individual is required to have a primary care provider but can also self-
refer to other in-network specialists as needed
Exclusive Provider Organizations (EPO) -- Answer ✔✔ -No referral
-No PCP
-Services are covered only if patients use doctors, specialists, or hospitals in the plan's
network (except in an emergency).
-No out-of-network benefits.
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
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)
QUESTIONS WITH COMPLETE SOLUTIONS
What is an ACO? -- Answer ✔✔ A system of providers and facilities that can work in
concert to care for a given patient population
What is the purpose of the comprehension accreditation process? -- Answer ✔✔ To
evaluate an organization's compliance with the CMS COP standards and other
accreditation requirements
What was the aim of the HMO Act of 1973? -- Answer ✔✔ To change the system of
health care delivery.
HMO Act 1973 -- Answer ✔✔ -The original HMO Act was designed to create new
physician groups that would act as
prepaid practice groups (PPGs).
-HMO concept was to create a seamless integration of comprehensive care delivery
with a
financing mechanism for benefits. These benefit plans would remove most deductibles
and
copays, and also cover preventive services that were previously excluded by all insurers
Effects of the HMO Act -- Answer ✔✔ -The new law 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 by section 1310 of the HMO Act to make a dual
choice available to their employees. This meant that employees would have a choice to
select one or more HMOs or select the employer's traditional insurance plan.
,To be eligible for COBRA coverage, an employee must have: -- Answer ✔✔ Been
enrolled in an employer's health plan while working and the health plan must continue
to be in effect for active employees.
What is the purpose of Consolidated Omnibus Budget Reconciliation Act (COBRA)
legislation? -- Answer ✔✔ To provide continuation of group health coverage that
otherwise might be terminated
What is one purpose of the Emergency Medical Treatment and Active Labor Act
(EMTALA)? -- Answer ✔✔ To govern when and how a patient presenting at a hospital
may be refused treatment
What is the purpose of the URAC? -- Answer ✔✔ To promote healthcare quality
through accreditation and certification programs
Which options are a focus of the HIPAA Title II series of laws? -- Answer ✔✔ -Health
care access, portability, and renewability
-To maintain the efficiency and effectiveness of the electronic transmission of health
information.
-Health care claim professional (837P), health care claim dental (837D), and health care
claim payment/advice (835)
What was the expectation of the 2010 Patient Protection and Affordable Care Act
(PPACA)? -- Answer ✔✔ To bring coverage to millions of Americans who could not or
would not purchase health insurance
What is Managed Care? -- Answer ✔✔ 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)
Health Maintenance Organizations (HMO) -- Answer ✔✔ -Referralso 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)
Preferred Provider Organizations (PPO) -- Answer ✔✔ -No referrals
-No PCP
-Reimbursement - discounted fee-for-service based model, where providers are
contractually obligated to provide covered persons with specific services at discounted
rates. This may also be accompanied by a utilization review mechanism embedded in the
contract to manage costs over time.
Point of Service (POS) Organizations -- Answer ✔✔ -No referrals
-PCP
-Combine features of both an HMO and PPO
-A covered individual is required to have a primary care provider but can also self-
refer to other in-network specialists as needed
Exclusive Provider Organizations (EPO) -- Answer ✔✔ -No referral
-No PCP
-Services are covered only if patients use doctors, specialists, or hospitals in the plan's
network (except in an emergency).
-No out-of-network benefits.
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
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)
