CSPR - Certified Specialist Payment Rep (HFMA)
Exam 2024 Questions And Answers Graded A+
Steps used to control costs of managed care include:
Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify
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
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:
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:
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
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)
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:
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
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?
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:
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?
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?
Exam 2024 Questions And Answers Graded A+
Steps used to control costs of managed care include:
Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify
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
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:
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:
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
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)
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:
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
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?
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:
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?
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?
