CSPR - Certified Specialist Payment Rep
(HFMA) questions with correct
answers
,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
(HFMA) questions with correct
answers
,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
