CSPR - Certified Specialist Payment Rep
(HFMA)Questions And Answers
Steps bused bto bcontrol bcosts bof bmanaged bcare binclude: b- bcorrect
banswer✔✔Bundled bcodes
Capitation b
Payer band bProvider bto bagree bon breasonable bpayment
DRG bis bused bto bclassify b- bcorrect banswer✔✔Inpatient badmissions bfor bthe bpurpose
bof breimbursing bhospitals bfor beach bcase bin ba bgiven bcategory bw/a bnegotiated bfixed
bfee, bregardless bof bthe bactual bcosts bincurred
Identify bthe bvarious btypes bof bprivate bhealth bplan bcoverage b- bcorrect
banswer✔✔HMO
Conventional
PPO band bPOS
HDHP/SO bplans b- bhigh-deductible bhealth bplans bwith ba bsavings boption; bPrivate b-
bInclude bhigher bpatient bout-of-pocket bexpenditures bfor btreatments bthat bcan bserve bto
breduce butilization/costs.
Managed bcare borganizations b(MCO) bexist bprimarily bin bfour bforms: b- bcorrect
banswer✔✔Health bMaintenance bOrganizations b(HMO)
Preferred bProvider bOrganizations b(PPO)
Point bof bService b(POS) bOrganizations
Exclusive bProvider bOrganizations b(EPO)
Identify bthe bvarious btypes bof bgovernment‐sponsored bhealth bcoverage: b- bcorrect
banswer✔✔Medicare b- bGovernment; bBeneficiaries benrolled bin bsuch bplans, bbut,
bparticipation bin bthese
plans bis bvoluntary.
Medicaid
Medicaid bManaged bCare b- bMedicaid bbeneficiaries bare brequired bto bselect band
benroll bin ba bmanaged bcare bplan.
Medicare bManaged bCare b(a.k.a. bMedicare bAdvantage bPlans)
,Identify bsome bkey bdrivers bof bincreasing bhealthcare bcosts b- bcorrect
banswer✔✔Demographics
Chronic bConditions
Provider bpayment bsystems b- bProvider bpayment bsystems bthat bare bdesigned bto
breward bvolume brather bthan bquality, boutcomes, band bprevention
Consumer bPerceptions
Health bPlan bpressure
Physician bRelationships
Supply bChain
Health bMaintenance bOrganizations b(HMO) b- bcorrect banswer✔✔Referrals
PCP
Patients bmust buse ban bin-network bprovider bfor btheir bservices bto bbe bcovered.
Reimbursement b- bmajority bof bservices boffered bare breimbursed bthrough bcapitation
bpayments b(PMPM)
Medicare bis bcomposed bof bfour bparts: b- bcorrect banswer✔✔Part bA b- bprovides
binpatient/hospital, bhospice, band bskilled bnursing bcoverage
Part bB b- bprovides boutpatient/medical bcoverage
Part bC b- ban balternative bway bto breceive byour bMedicare bbenefits b(known bas
bMedicare
Advantage)
Part bD b- bprescription bdrug bcoverage
HMO bAct bof b1973 b- bcorrect banswer✔✔The bHMO bAct bof b1973 bgave bfederally
bqualified bHMOs bthe bright bto bmandate bthat bemployers boffer btheir bproduct bto btheir
bemployees bunder bcertain bconditions. bMandating ban bemployer bmeant bthat
bemployers bwho bhad b25 bor bmore bemployees band bwere bfor‐profit bcompanies bwere
brequired bto bmake ba bdual bchoice bavailable bto btheir bemployees.
Which bof bthe bfollowing bstatements bregarding bemployer-based bhealth binsurance bin
bthe bUnited bStates bis btrue? b- bcorrect banswer✔✔The breal badvent bof bemployer-
based binsurance bcame bthrough bBlue bCross, bwhich bwas bstarted bby bhospital
bassociations bduring bthe bDepression.
The bHealth bMaintenance bOrganization b(HMO) bAct bof b1973 bgave bqualified bHMOs
bthe bright bto b"mandate" ban bemployer bunder bcertain bconditions, bmeaning
bemployers: b- bcorrect banswer✔✔Would bhave bto boffer bHMO bplans balong bside
btraditional bfee-for-service bmedical bplans.
Which bof bthe bfollowing bis ban banticipated bchange bin bthe brelationships bbetween
bconsumers band bproviders? b- bcorrect banswer✔✔Providers bwill bface bmany bnew
bservice bdemands band bconsumers bwill bhave bvirtually bunfettered baccess bto bthose
bservices
, What btransition bbegan bas ba bresult bof bthe bMarch b2010 bhealthcare breform
blegislation? b- bcorrect banswer✔✔A btransition btoward bnew bmodels bof bhealth bcare
bdelivery bwith bcorresponding bchanges bsystem bfinancing band bprovider
breimbursement.
Which bstatement bis bfalse bconcerning bABNs? b- bcorrect banswer✔✔ABN bbegan
bestablishing bnew brequirements bfor bmanaged bcare bplans bparticipating bin bthe
bMedicare bprogram.
Which bStatement bis bTRUE bconcerning bABNs? b- bcorrect banswer✔✔-ABNs bare bnot
brequired bfor bservices bthat bare bnever bcovered bby bMedicare.
-An bABN bform bnotifies bthe bpatient bbefore bhe bor bshe breceives bthe bservice bthat bit
bmay bnot bbe
covered bby bMedicare band bthat bhe bor bshe bwill bneed bto bpay bout bof bpocket.
-Although bABNs bcan bhave bsignificant bfinancial bimplications bfor bthe bphysician, bthey
balso
serve ban bimportant bfraud band babuse bcompliance bfunction.
What bis bthe boverall bfunction bof bMedicaid? b- bcorrect banswer✔✔The bpay bfor
bmedical bassistance bfor bcertain bindividuals band blow-income bfamilies
Medical bCost bRatio b(MCR) bor bMedical bLoss bRatio b(MLR) bis bdefined bas: b- bcorrect
banswer✔✔Total bMedical bExpenses bdivided bby bTotal bPremiums
Provider bservice borganizations b(PSOs) bfunction blike bhealth bmaintenance
borganizations b(HMOs) bin ball bof bthe bfollowing bways, bEXCEPT: b- bcorrect
banswer✔✔Ties bto bthe bhealthcare bdelivery bindustry brather bthan bthe binsurance
bindustry
Provider bservice borganizations b(PSOs) bfunction blike bhealth bmaintenance
borganizations b(HMOs) bin ball bof bthe bfollowing bways: b- bcorrect banswer✔✔-Risk
bpooling
-Capitalization
-Network bmanagement
Which bof bthe bfollowing bis ba bservice bprovided bby ba bwell-managed bthird-party
badministrator b(TPA)? b- bcorrect banswer✔✔-Administrative
-Utilization breview b(UR) b
-Claims bprocessing
What bis btiering? b- bcorrect banswer✔✔The branking bor bclassifying bof bone bor bmore bof
bthe bprovider bdelivery bsystem bcomponents
Which boption bis ba bpractice bused bto bcontrol bcosts bof bmanaged bcare? b- bcorrect
banswer✔✔-Making badvance bpayment bto bproviders bfor ball bservices bneeded bto bcare
bfor ba bmember
(HFMA)Questions And Answers
Steps bused bto bcontrol bcosts bof bmanaged bcare binclude: b- bcorrect
banswer✔✔Bundled bcodes
Capitation b
Payer band bProvider bto bagree bon breasonable bpayment
DRG bis bused bto bclassify b- bcorrect banswer✔✔Inpatient badmissions bfor bthe bpurpose
bof breimbursing bhospitals bfor beach bcase bin ba bgiven bcategory bw/a bnegotiated bfixed
bfee, bregardless bof bthe bactual bcosts bincurred
Identify bthe bvarious btypes bof bprivate bhealth bplan bcoverage b- bcorrect
banswer✔✔HMO
Conventional
PPO band bPOS
HDHP/SO bplans b- bhigh-deductible bhealth bplans bwith ba bsavings boption; bPrivate b-
bInclude bhigher bpatient bout-of-pocket bexpenditures bfor btreatments bthat bcan bserve bto
breduce butilization/costs.
Managed bcare borganizations b(MCO) bexist bprimarily bin bfour bforms: b- bcorrect
banswer✔✔Health bMaintenance bOrganizations b(HMO)
Preferred bProvider bOrganizations b(PPO)
Point bof bService b(POS) bOrganizations
Exclusive bProvider bOrganizations b(EPO)
Identify bthe bvarious btypes bof bgovernment‐sponsored bhealth bcoverage: b- bcorrect
banswer✔✔Medicare b- bGovernment; bBeneficiaries benrolled bin bsuch bplans, bbut,
bparticipation bin bthese
plans bis bvoluntary.
Medicaid
Medicaid bManaged bCare b- bMedicaid bbeneficiaries bare brequired bto bselect band
benroll bin ba bmanaged bcare bplan.
Medicare bManaged bCare b(a.k.a. bMedicare bAdvantage bPlans)
,Identify bsome bkey bdrivers bof bincreasing bhealthcare bcosts b- bcorrect
banswer✔✔Demographics
Chronic bConditions
Provider bpayment bsystems b- bProvider bpayment bsystems bthat bare bdesigned bto
breward bvolume brather bthan bquality, boutcomes, band bprevention
Consumer bPerceptions
Health bPlan bpressure
Physician bRelationships
Supply bChain
Health bMaintenance bOrganizations b(HMO) b- bcorrect banswer✔✔Referrals
PCP
Patients bmust buse ban bin-network bprovider bfor btheir bservices bto bbe bcovered.
Reimbursement b- bmajority bof bservices boffered bare breimbursed bthrough bcapitation
bpayments b(PMPM)
Medicare bis bcomposed bof bfour bparts: b- bcorrect banswer✔✔Part bA b- bprovides
binpatient/hospital, bhospice, band bskilled bnursing bcoverage
Part bB b- bprovides boutpatient/medical bcoverage
Part bC b- ban balternative bway bto breceive byour bMedicare bbenefits b(known bas
bMedicare
Advantage)
Part bD b- bprescription bdrug bcoverage
HMO bAct bof b1973 b- bcorrect banswer✔✔The bHMO bAct bof b1973 bgave bfederally
bqualified bHMOs bthe bright bto bmandate bthat bemployers boffer btheir bproduct bto btheir
bemployees bunder bcertain bconditions. bMandating ban bemployer bmeant bthat
bemployers bwho bhad b25 bor bmore bemployees band bwere bfor‐profit bcompanies bwere
brequired bto bmake ba bdual bchoice bavailable bto btheir bemployees.
Which bof bthe bfollowing bstatements bregarding bemployer-based bhealth binsurance bin
bthe bUnited bStates bis btrue? b- bcorrect banswer✔✔The breal badvent bof bemployer-
based binsurance bcame bthrough bBlue bCross, bwhich bwas bstarted bby bhospital
bassociations bduring bthe bDepression.
The bHealth bMaintenance bOrganization b(HMO) bAct bof b1973 bgave bqualified bHMOs
bthe bright bto b"mandate" ban bemployer bunder bcertain bconditions, bmeaning
bemployers: b- bcorrect banswer✔✔Would bhave bto boffer bHMO bplans balong bside
btraditional bfee-for-service bmedical bplans.
Which bof bthe bfollowing bis ban banticipated bchange bin bthe brelationships bbetween
bconsumers band bproviders? b- bcorrect banswer✔✔Providers bwill bface bmany bnew
bservice bdemands band bconsumers bwill bhave bvirtually bunfettered baccess bto bthose
bservices
, What btransition bbegan bas ba bresult bof bthe bMarch b2010 bhealthcare breform
blegislation? b- bcorrect banswer✔✔A btransition btoward bnew bmodels bof bhealth bcare
bdelivery bwith bcorresponding bchanges bsystem bfinancing band bprovider
breimbursement.
Which bstatement bis bfalse bconcerning bABNs? b- bcorrect banswer✔✔ABN bbegan
bestablishing bnew brequirements bfor bmanaged bcare bplans bparticipating bin bthe
bMedicare bprogram.
Which bStatement bis bTRUE bconcerning bABNs? b- bcorrect banswer✔✔-ABNs bare bnot
brequired bfor bservices bthat bare bnever bcovered bby bMedicare.
-An bABN bform bnotifies bthe bpatient bbefore bhe bor bshe breceives bthe bservice bthat bit
bmay bnot bbe
covered bby bMedicare band bthat bhe bor bshe bwill bneed bto bpay bout bof bpocket.
-Although bABNs bcan bhave bsignificant bfinancial bimplications bfor bthe bphysician, bthey
balso
serve ban bimportant bfraud band babuse bcompliance bfunction.
What bis bthe boverall bfunction bof bMedicaid? b- bcorrect banswer✔✔The bpay bfor
bmedical bassistance bfor bcertain bindividuals band blow-income bfamilies
Medical bCost bRatio b(MCR) bor bMedical bLoss bRatio b(MLR) bis bdefined bas: b- bcorrect
banswer✔✔Total bMedical bExpenses bdivided bby bTotal bPremiums
Provider bservice borganizations b(PSOs) bfunction blike bhealth bmaintenance
borganizations b(HMOs) bin ball bof bthe bfollowing bways, bEXCEPT: b- bcorrect
banswer✔✔Ties bto bthe bhealthcare bdelivery bindustry brather bthan bthe binsurance
bindustry
Provider bservice borganizations b(PSOs) bfunction blike bhealth bmaintenance
borganizations b(HMOs) bin ball bof bthe bfollowing bways: b- bcorrect banswer✔✔-Risk
bpooling
-Capitalization
-Network bmanagement
Which bof bthe bfollowing bis ba bservice bprovided bby ba bwell-managed bthird-party
badministrator b(TPA)? b- bcorrect banswer✔✔-Administrative
-Utilization breview b(UR) b
-Claims bprocessing
What bis btiering? b- bcorrect banswer✔✔The branking bor bclassifying bof bone bor bmore bof
bthe bprovider bdelivery bsystem bcomponents
Which boption bis ba bpractice bused bto bcontrol bcosts bof bmanaged bcare? b- bcorrect
banswer✔✔-Making badvance bpayment bto bproviders bfor ball bservices bneeded bto bcare
bfor ba bmember
