CSPR - Certified Specialist Payment Rep
(HFMA) QUESTIONS AND ANSWERS
1. A fixed payment amount based totally upon the quantity of participants assigned to a
provider, and does not range based totally upon the number of offerings rendered, is
known as: - ANS-Capitation
2. According to MedPAC, which alternative is a advantage or undesirable result of bundling
payments? - ANS--It lets in Medicare to pay a set rate in step with hospitalization
episode.
-It might provide the capacity to enhance efficiency and excellent
-It could cause underutilization of services
3. Advanced Beneficiary Notice (ABN): Potential Service Denials - ANS-Although
commonly covered by Medicare, the subsequent services are probable to be
denied for lack of clinical necessity underneath the situations described beneath:
-Lab Tests - Lab checks (as an instance, entire blood be counted) while the
diagnosis code does
not support Medicare's definition of medical necessity.
-Pap Smear - A screening Pap smear and pelvic examination given greater often
than each years, except the beneficiary is in a class for which annual checks are
included
-Screening Fecal Occult Blood Test - A screening fecal occult blood check given
more often
than yearly or if the beneficiary is more youthful than 50 years
-Screening flexible sigmoidoscopy - A screening bendy sigmoidoscopy given
extra often
than each four years or if the beneficiary is younger than 45 years
-Prostate Cancer Screening - A prostate cancer screening take a look at given
more often than
yearly or if the beneficiary is more youthful than 50 years
-Tetanus vaccine - A tetanus vaccine given prophylactically (in comparison to 1
given
because the affected person stepped on a rusty nail)
-Local Medical Review Policy (LMRP) - Any service that does not meet the
insurance standards
hooked up in Local Medical Review Policy (LMRP). Some Medicare carriers have
set up
particular insurance criteria. For instance, a few vendors have hooked up LMRPs
for common
workplace tactics along with removal of benign skin lesions. You can discover
LMRPs via the
website of your nearby Medicare carrier.
,4. Aligning incentives has come to mean _________. - ANS-The suitable addition of
some chance inside the alternate of fitness care to a patient for some shape of
remuneration.
5. All of the following are effective settlement assessment standards, EXCEPT: -
ANS-Detailed agreement overall performance assessments
6. All of the subsequent are effective settlement evaluation criteria: - ANS--General payer
or provider standards
-Reimbursement stages and parameters
-Provider prices and responsibilities
7. All of the following are duties of a provider organisation's Board of Directors, EXCEPT: -
ANS-Implementation issues
8. All of the following are duties of a issuer agency's Board of Directors: - ANS--Fiduciary
topics
-Legal affairs
-Policy subjects
9. All of the following have to be analyzed previous to and/or for the duration of contract
negotiations, EXCEPT: - ANS-Historical member rates
10. All of the subsequent have to be analyzed prior to and/or at some point of contract
negotiations: - ANS--Member volumes with the aid of product type
-Historical compensation levels by product kind
-Historical claims price and/or submission issues
11. As the healthcare industry actions to control boom in scientific spending, what initiative
can assist hospitals keep their margins? - ANS-Contract standardization
12. As the healthcare industry actions to manipulate growth in medical spending, what
initiative can NOT assist hospitals keep their margins? - ANS--Pay-for-overall
performance packages
-Health savings debts
-Price transparency
13. Base MS-DRG payment, hospitals acquire adjusted repayment for the subsequent
classes of fees: - ANS--Cost Outliers - Cost Outliers are defined as cases related to
extraordinary lengths of
stay or odd cost
-Transfer Policy - Reduced payments for quick live patients
-Direct/Indirect Medical Education - Direct and indirect costs of affected person
care associated with operating permitted graduate clinical schooling application.
Reimbursement is based totally on the ratio of interns and citizens to medical
institution beds (IRB).
-Disportionate Share - Hospitals that serve a big indigent populace may
qualify as a disproportionate share hospital and acquire a further quantity
determined with the aid of a components based totally on the proportion of
Supplemental Security
Income (SSI) and Medicaid patients. Distribution of funds is based at the
sanatorium's percentage of countrywide uncompensated take care of all Medicare
DSH hospitals.
, -End-Stage Renal Disease - Payment is calculated the use of a formula that
incorporates the weekly value of dialysis (composite charge).
14. Catastrophic Case Management - ANS-used to manage diseases associated with
very high costs of care.
15. Clear implications for CDHP clients include the subsequent: - ANS--More Financial
Burden‐CDHPs shift greater top class possibilities to the purchaser and have
better copayments, deductibles, and stop‐loss thresholds than conventional
controlled care plans.
-Accountability for Healthcare Use‐Some plans provide individuals factors for
lifestyles style behaviors that help higher health (points for nonsmokers, exercise,
and many others.).
-Shopping for Health Care‐Consumers are incentivized to investigate the most
suitable healthcare issuer. Many payer websites now have economic calculators
to help purchasers decide what their price can be underneath their advantage
plan.
-Record Keeping - Consumers can be required to track claims and bills to account
for out‐of‐pocket prices, copayments, and deductible thresholds. In addition, the
HRA element and prevent‐loss coverage upload in addition complexity. Many of
the CDHPs have equipment to help participants track claims, however this may be
a burden for customers to bear.
16. CMS is liable for: - ANS--clear coverage on eligibility for CMS programs, coverage
and compensation of healthcare services, requirements for carriers, and program
management.
-Administration of comprehensive agreements with contractors and states; the
performance standards that must be met of their management, and the
programmatic consequences which are to be executed.
-Monitoring the performance of contractors and states
17. Consumer benefits for CDHPs include the following: - ANS--Coverage ‐ CDHPs permit
customers to purchase insurance for matters now not generally protected by way
of HMOs or other benefit plans (inclusive of laser eye surgical operation and
acupuncture).
-Access ‐ There are fewer obstacles to health practitioner access (along with
referral mechanisms and preauthorization requirements) in CDHPs.
-Choice ‐ CDHPs constitute an extra benefit plan desire that provides to the
common twin‐desire (HMO, PPO) services of employers.
18. Diagnosis-associated institution (DRG) is: - ANS-A payment category
19. Direct contracting - ANS-described as unmarried‐organization or multi‐company
healthcare alliances that settlement directly with vendors for healthcare offerings.
20. Dispute decision techniques consist of the following: - ANS--Dispute decision in which
the settlement is silent
-Dispute resolution thru mediation
-Dispute decision through arbitration—binding or non-binding
(HFMA) QUESTIONS AND ANSWERS
1. A fixed payment amount based totally upon the quantity of participants assigned to a
provider, and does not range based totally upon the number of offerings rendered, is
known as: - ANS-Capitation
2. According to MedPAC, which alternative is a advantage or undesirable result of bundling
payments? - ANS--It lets in Medicare to pay a set rate in step with hospitalization
episode.
-It might provide the capacity to enhance efficiency and excellent
-It could cause underutilization of services
3. Advanced Beneficiary Notice (ABN): Potential Service Denials - ANS-Although
commonly covered by Medicare, the subsequent services are probable to be
denied for lack of clinical necessity underneath the situations described beneath:
-Lab Tests - Lab checks (as an instance, entire blood be counted) while the
diagnosis code does
not support Medicare's definition of medical necessity.
-Pap Smear - A screening Pap smear and pelvic examination given greater often
than each years, except the beneficiary is in a class for which annual checks are
included
-Screening Fecal Occult Blood Test - A screening fecal occult blood check given
more often
than yearly or if the beneficiary is more youthful than 50 years
-Screening flexible sigmoidoscopy - A screening bendy sigmoidoscopy given
extra often
than each four years or if the beneficiary is younger than 45 years
-Prostate Cancer Screening - A prostate cancer screening take a look at given
more often than
yearly or if the beneficiary is more youthful than 50 years
-Tetanus vaccine - A tetanus vaccine given prophylactically (in comparison to 1
given
because the affected person stepped on a rusty nail)
-Local Medical Review Policy (LMRP) - Any service that does not meet the
insurance standards
hooked up in Local Medical Review Policy (LMRP). Some Medicare carriers have
set up
particular insurance criteria. For instance, a few vendors have hooked up LMRPs
for common
workplace tactics along with removal of benign skin lesions. You can discover
LMRPs via the
website of your nearby Medicare carrier.
,4. Aligning incentives has come to mean _________. - ANS-The suitable addition of
some chance inside the alternate of fitness care to a patient for some shape of
remuneration.
5. All of the following are effective settlement assessment standards, EXCEPT: -
ANS-Detailed agreement overall performance assessments
6. All of the subsequent are effective settlement evaluation criteria: - ANS--General payer
or provider standards
-Reimbursement stages and parameters
-Provider prices and responsibilities
7. All of the following are duties of a provider organisation's Board of Directors, EXCEPT: -
ANS-Implementation issues
8. All of the following are duties of a issuer agency's Board of Directors: - ANS--Fiduciary
topics
-Legal affairs
-Policy subjects
9. All of the following have to be analyzed previous to and/or for the duration of contract
negotiations, EXCEPT: - ANS-Historical member rates
10. All of the subsequent have to be analyzed prior to and/or at some point of contract
negotiations: - ANS--Member volumes with the aid of product type
-Historical compensation levels by product kind
-Historical claims price and/or submission issues
11. As the healthcare industry actions to control boom in scientific spending, what initiative
can assist hospitals keep their margins? - ANS-Contract standardization
12. As the healthcare industry actions to manipulate growth in medical spending, what
initiative can NOT assist hospitals keep their margins? - ANS--Pay-for-overall
performance packages
-Health savings debts
-Price transparency
13. Base MS-DRG payment, hospitals acquire adjusted repayment for the subsequent
classes of fees: - ANS--Cost Outliers - Cost Outliers are defined as cases related to
extraordinary lengths of
stay or odd cost
-Transfer Policy - Reduced payments for quick live patients
-Direct/Indirect Medical Education - Direct and indirect costs of affected person
care associated with operating permitted graduate clinical schooling application.
Reimbursement is based totally on the ratio of interns and citizens to medical
institution beds (IRB).
-Disportionate Share - Hospitals that serve a big indigent populace may
qualify as a disproportionate share hospital and acquire a further quantity
determined with the aid of a components based totally on the proportion of
Supplemental Security
Income (SSI) and Medicaid patients. Distribution of funds is based at the
sanatorium's percentage of countrywide uncompensated take care of all Medicare
DSH hospitals.
, -End-Stage Renal Disease - Payment is calculated the use of a formula that
incorporates the weekly value of dialysis (composite charge).
14. Catastrophic Case Management - ANS-used to manage diseases associated with
very high costs of care.
15. Clear implications for CDHP clients include the subsequent: - ANS--More Financial
Burden‐CDHPs shift greater top class possibilities to the purchaser and have
better copayments, deductibles, and stop‐loss thresholds than conventional
controlled care plans.
-Accountability for Healthcare Use‐Some plans provide individuals factors for
lifestyles style behaviors that help higher health (points for nonsmokers, exercise,
and many others.).
-Shopping for Health Care‐Consumers are incentivized to investigate the most
suitable healthcare issuer. Many payer websites now have economic calculators
to help purchasers decide what their price can be underneath their advantage
plan.
-Record Keeping - Consumers can be required to track claims and bills to account
for out‐of‐pocket prices, copayments, and deductible thresholds. In addition, the
HRA element and prevent‐loss coverage upload in addition complexity. Many of
the CDHPs have equipment to help participants track claims, however this may be
a burden for customers to bear.
16. CMS is liable for: - ANS--clear coverage on eligibility for CMS programs, coverage
and compensation of healthcare services, requirements for carriers, and program
management.
-Administration of comprehensive agreements with contractors and states; the
performance standards that must be met of their management, and the
programmatic consequences which are to be executed.
-Monitoring the performance of contractors and states
17. Consumer benefits for CDHPs include the following: - ANS--Coverage ‐ CDHPs permit
customers to purchase insurance for matters now not generally protected by way
of HMOs or other benefit plans (inclusive of laser eye surgical operation and
acupuncture).
-Access ‐ There are fewer obstacles to health practitioner access (along with
referral mechanisms and preauthorization requirements) in CDHPs.
-Choice ‐ CDHPs constitute an extra benefit plan desire that provides to the
common twin‐desire (HMO, PPO) services of employers.
18. Diagnosis-associated institution (DRG) is: - ANS-A payment category
19. Direct contracting - ANS-described as unmarried‐organization or multi‐company
healthcare alliances that settlement directly with vendors for healthcare offerings.
20. Dispute decision techniques consist of the following: - ANS--Dispute decision in which
the settlement is silent
-Dispute resolution thru mediation
-Dispute decision through arbitration—binding or non-binding
