CSRP CERTIFIED SPACIALIST HFMA -2025-
COMPLEHENCIVE QUESTIONS WITH ACCUERATE
ANSWERS ALREADY GRADED A+ QUARANTEED
SUCCESS
What is direct contracting? - correct answer > A single-employer or multi-
employer healthcare alliances that contract directly with providers for healthcare
services
What is a non-directed PPO? - correct answer > A payer that has contracted either
directly or indirectly with the provider to access preferred rates
All of the following are responsibilities of a provider organization's Board of
Directors, EXCEPT: - correct answer > Implementation issues
Which option is considered a key difference between inpatient and outpatient
contracting? - correct answer > -Reimbursement methodology differences
-Operational policies and procedures
-Market differences affecting outpatient and inpatient volumes
All of the following should be analyzed prior to and/or during contract
negotiations, EXCEPT: - correct answer > Historical member premiums
All of the following should be analyzed prior to and/or during contract
negotiations: - correct answer > -Member volumes by product type
-Historical reimbursement levels by product type
, 2
-Historical claims payment and/or submission problems
Which of the following is a service provided by a well-managed third-party
administrator (TPA)? - correct answer > -Administrative
-Utilization review (UR)
-Claims processing
What is tiering? - correct answer > The ranking or classifying of one or more of the
provider delivery system components
Which option is a practice used to control costs of managed care? - correct
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 Managed care organizations (MCO) exist primarily in four forms: - correct
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: - correct
answer > Medicare - Government; Beneficiaries enrolled in such plans, but,
participation in these
plans is voluntary.
, 3
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)
All of the following are responsibilities of a provider organization's Board of
Directors: - correct answer > -Fiduciary matters
-Legal affairs
-Policy matters
Health Maintenance Organizations (HMO) - correct 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: - correct 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 - correct answer > The HMO Act of 1973 gave federally qualified
HMOs the right to mandate that employers offer their product to their employees
, 4
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? - correct 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: - correct 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? - correct 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? - correct answer > A transition toward new models of health care
delivery with corresponding changes system financing and provider
reimbursement.
Which statement is false concerning ABNs? - correct answer > ABN began
establishing new requirements for managed care plans participating in the
Medicare program.
Which Statement is TRUE concerning ABNs? - correct answer > -ABNs are not
required for services that are never covered by Medicare.
COMPLEHENCIVE QUESTIONS WITH ACCUERATE
ANSWERS ALREADY GRADED A+ QUARANTEED
SUCCESS
What is direct contracting? - correct answer > A single-employer or multi-
employer healthcare alliances that contract directly with providers for healthcare
services
What is a non-directed PPO? - correct answer > A payer that has contracted either
directly or indirectly with the provider to access preferred rates
All of the following are responsibilities of a provider organization's Board of
Directors, EXCEPT: - correct answer > Implementation issues
Which option is considered a key difference between inpatient and outpatient
contracting? - correct answer > -Reimbursement methodology differences
-Operational policies and procedures
-Market differences affecting outpatient and inpatient volumes
All of the following should be analyzed prior to and/or during contract
negotiations, EXCEPT: - correct answer > Historical member premiums
All of the following should be analyzed prior to and/or during contract
negotiations: - correct answer > -Member volumes by product type
-Historical reimbursement levels by product type
, 2
-Historical claims payment and/or submission problems
Which of the following is a service provided by a well-managed third-party
administrator (TPA)? - correct answer > -Administrative
-Utilization review (UR)
-Claims processing
What is tiering? - correct answer > The ranking or classifying of one or more of the
provider delivery system components
Which option is a practice used to control costs of managed care? - correct
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 Managed care organizations (MCO) exist primarily in four forms: - correct
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: - correct
answer > Medicare - Government; Beneficiaries enrolled in such plans, but,
participation in these
plans is voluntary.
, 3
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)
All of the following are responsibilities of a provider organization's Board of
Directors: - correct answer > -Fiduciary matters
-Legal affairs
-Policy matters
Health Maintenance Organizations (HMO) - correct 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: - correct 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 - correct answer > The HMO Act of 1973 gave federally qualified
HMOs the right to mandate that employers offer their product to their employees
, 4
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? - correct 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: - correct 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? - correct 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? - correct answer > A transition toward new models of health care
delivery with corresponding changes system financing and provider
reimbursement.
Which statement is false concerning ABNs? - correct answer > ABN began
establishing new requirements for managed care plans participating in the
Medicare program.
Which Statement is TRUE concerning ABNs? - correct answer > -ABNs are not
required for services that are never covered by Medicare.
