CSPR - Certified Specialist Payment Rep
(HFMA)
Steps used to control costs of managed care include: - correct answers
Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - correct answers 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
Identify the various types of private health plan coverage - correct
answers 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.
Managed care organizations (MCO) exist primarily in four forms: -
correct answers 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 answers 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)
Identify some key drivers of increasing healthcare costs - correct
answers 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
,Health Maintenance Organizations (HMO) - correct answers 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 answers 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 answers The HMO Act of 1973 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 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 answers 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 answers 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 answers 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 answers A transition toward new models of health
care delivery with corresponding changes system financing and provider
reimbursement.
Which statement is false concerning ABNs? - correct answers ABN
began establishing new requirements for managed care plans
participating in the Medicare program.
(HFMA)
Steps used to control costs of managed care include: - correct answers
Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - correct answers 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
Identify the various types of private health plan coverage - correct
answers 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.
Managed care organizations (MCO) exist primarily in four forms: -
correct answers 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 answers 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)
Identify some key drivers of increasing healthcare costs - correct
answers 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
,Health Maintenance Organizations (HMO) - correct answers 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 answers 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 answers The HMO Act of 1973 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 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 answers 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 answers 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 answers 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 answers A transition toward new models of health
care delivery with corresponding changes system financing and provider
reimbursement.
Which statement is false concerning ABNs? - correct answers ABN
began establishing new requirements for managed care plans
participating in the Medicare program.
