HFMA CSPR EXAM 2 ACTUAL EXAM 2024-25 COMPLETE REAL QUESTIONS AND CORRECT ANSWERS (CORRECT VERIFIED SOLUTIONS) LATEST UPDATED VERSION

CSPR - u




u Certified Specialist Payment Rep (HFMA) u u u u




Steps used to control costs of managed care include: -
u u u u u u u u u



correct answers Bundled codes
u u u u




Capitation u




Payer and Provider to agree on reasonable payment
u u u u u u u




DRG is used to classify -
u u u u u



correct answers Inpatient admissions for the purpose of reimbursing hos
u u u u u u u u u u



pitals for each case in a given category w/a negotiated fixed fee, regardles
u u u u u u u u u u u u



s of the actual costs incurred
u u u u u




Identify the various types of private health plan coverage -
u u u u u u u u u



ucorrect answers HMO u u




Conventional
PPO and POS u u




HDHP/SO plans - high- u u u



deductible health plans with a savings option; Private -
u u u u u u u u



Include higher patient out-of-
u u u u



pocket expenditures for treatments that can serve to reduce utilization/c
u u u u u u u u u



osts.

,Managed care organizations (MCO) exist primarily in four forms: -
u u u u u u u u u



correct answers Health Maintenance Organizations (HMO)
u u u u u u




Preferred Provider Organizations (PPO)
u u u




Point of Service (POS) Organizations
u u u u




Exclusive Provider Organizations (EPO)
u u u




Identify the various types of government-sponsored health coverage: -
u u u u u u u u



ucorrect answers Medicare -
u u u



uGovernment; Beneficiaries enrolled in such plans, but, participation in th
u u u u u u u u u



ese
plans is voluntary.
u u




Medicaid
Medicaid Managed Care - u u u



Medicaid beneficiaries are required to select and enroll in a managed car
u u u u u u u u u u u u



e plan.
u




Medicare Managed Care (a.k.a. Medicare Advantage Plans)
u u u u u u




Identify some key drivers of increasing healthcare costs -
u u u u u u u u



ucorrect answers Demographics
u u




Chronic Conditions
u




Provider payment systems -
u u u



Provider payment systems that are designed to reward volume rather th
u u u u u u u u u u u



an quality, outcomes, and prevention
u u u u




Consumer Perceptions u

,Health Plan pressure u u




Physician Relationships u




Supply Chain u




Health Maintenance Organizations (HMO) - correct answers Referrals
u u u u u u u




PCP
Patients must use an in-network provider for their services to be covered.
u u u u u u u u u u u




Reimbursement - u



majority of services offered are reimbursed through capitation payments
u u u u u u u u u



(PMPM)
u




Medicare is composed of four parts: - correct answers Part A -
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provides inpatient/hospital, hospice, and skilled nursing coverage
u u u u u u u




Part B - provides outpatient/medical coverage
u u u u u




Part C -u u



an alternative way to receive your Medicare benefits (known as Medicar
u u u u u u u u u u u



e
Advantage)
Part D - prescription drug coverage
u u u u u




HMO Act of 1973 -
u u u u



correct answers The HMO Act of 1973 gave federally qualified HMOs the
u u u u u u u u u u u u u



right to mandate that employers offer their product to their employees u
u u u u u u u u u u u

, nder certain conditions. Mandating an employer meant that employers w
u u u u u u u u u



ho had 25 or more employees and were for-
u u u u u u u u



profit companies were required to make a dual choice available to their e
u u u u u u u u u u u u



mployees.


Which of the following statements regarding employer-
u u u u u u



based health insurance in the United States is true? -
u u u u u u u u u



correct answers The real advent of employer-
u u u u u u u



based insurance came through Blue Cross, which was started by hospital
u u u u u u u u u u u



associations during the Depression. u u u




The Health Maintenance Organization (HMO) Act of 1973 gave qualified
u u u u u u u u u u



HMOs the right to "mandate" an employer under certain conditions, mea
u u u u u u u u u u



ning employers: -
u u



ucorrect answers Would have to offer HMO plans along side traditional fee
u u u u u u u u u u u



-for-service medical plans. u u




Which of the following is an anticipated change in the relationships betw
u u u u u u u u u u u



een consumers and providers? -
u u u u



correct answers Providers will face many new service demands and cons
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umers will have virtually unfettered access to those services
u u u u u u u u




What transition began as a result of the March 2010 healthcare reform le
u u u u u u u u u u u u



gislation? - u



correct answers A transition toward new models of health care delivery
u u u u u u u u u u u u