(HFMA) -CERTIFIED SPECIALIST
PAYMENT REP-CSPR 2025/ 2026
QUESTIONS WITH VERIFIED
ANSWERS
Medicare Outpatient Observation Notice (MOON) - correct answer --requires hospitals and
Critical Access Hospitals (CAH) to provide notification to individuals receiving observation
services as outpatients for more than 24 hours explaining the status of the individual as an
outpatient, not an inpatient, and the implications of such status.
-Requirements - The MOON must be provided no later than 36 hours after observation services
are initiated or, if sooner, upon release. An oral explanation of the MOON must be provided,
ideally in conjunction with the delivery of the notice, and a signature must be obtained from the
individual, or a person acting on such individual's behalf, to acknowledge receipt. In cases
where such individual or person refuses to sign the MOON, the staff member of the hospital or
CAH providing the notice must sign the notice to certify that notification was presented.
Advanced Beneficiary Notice (ABN): Potential Service Denials - correct answer -Although
typically covered by Medicare, the following services are likely to be denied for lack of medical
necessity under the circumstances described below:
-Lab Tests - Lab tests (for example, complete blood count) when the diagnosis code does
not support Medicare's definition of medical necessity.
-Pap Smear - A screening Pap smear and pelvic exam given more often than every two years,
unless the beneficiary is in a category for which annual exams are covered
-Screening Fecal Occult Blood Test - A screening fecal occult blood test given more often
than annually or if the beneficiary is younger than 50 years
-Screening flexible sigmoidoscopy - A screening flexible sigmoidoscopy given more often
,than every four years or if the beneficiary is younger than 45 years
-Prostate Cancer Screening - A prostate cancer screening test given more often than
annually or if the beneficiary is younger than 50 years
-Tetanus vaccine - A tetanus vaccine given prophylactically (as compared to one given
because the patient stepped on a rusty nail)
-Local Medical Review Policy (LMRP) - Any service that does not meet the coverage criteria
established in Local Medical Review Policy (LMRP). Some Medicare carriers have established
specific coverage criteria. For example, some carriers have established LMRPs for common
office procedures such as removal of benign skin lesions. You can find LMRPs through the
website of your local Medicare carrier.
The various regulatory agencies in the healthcare industry include the following: - correct
answer --Centers for Medicare and Medicaid Services (CMS)
-Federal Trade Commission (FTC)
-Internal Revenue Service (IRS)
-Office of the Inspector General (OIG)
-Department of Justice (DOJ)
-Securities and Exchange Commission (SEC)
-The U.S. Public Health Service (PHS)
Managed Medicare enrollees now enjoy patient protections such as the following: - correct
answer -a) Information disclosure
b) Choice of providers and plans
c) Access to emergency services
d) Participation in treatment decisions
,e) Financial disclosure
f) Respect and nondiscrimination
g) Confidentiality of health information
h) Complaints and appeals
Tiering - correct answer -Tiering can be thought of as the ranking or classifying of one or more
of the provider
delivery system components or benefit design components of a typical managed care plan
to influence choice.
Tiered Provider Networks - correct answer --Delivery network tiering is an effort by insurers to
rein in costs and to address calls from employers and the public for improved quality.
-Tiered networks were first introduced after the cost-cutting success of tiered pharmacy plans
and formularies
Steps used to control costs of managed care include the following: - correct answer --One step -
For the payer and provider to agree on reasonable payment for each service. In general, this
payment arrangement results in payment rates that are beneath the rates that a provider would
charge to an uninsured individual.
-A next step - Might include combining services that are typically provided in conjunction with
one another and bundling the associated charges and determining an appropriate charge for
that set of services or type of care.
-Further efforts - Might include making advance payment to providers for all services needed to
care for a member. This form of payment is referred to as capitation, or per capita payment.
, The basic reimbursement methodologies used for hospital services include the following: -
correct answer --Percent-of-charge payments - A negotiated percentage off of billed charges
and can be applied to any or all of the services that the hospital provides.
-Per diem payments - Refers to a fixed amount per patient per inpatient day.
-Case rate payments - Represent a fixed price for specified care by paying an agreed-upon rate
for a specific healthcare service.
-Carve-outs - Sometimes refer to specific benefits or services that are administered separately
from the rest of the managed care plan and that may be managed by other third parties.
Professional services reimbursement methodologies include the following: - correct answer --
Discountsbasednegotiatedfeeschedules
-Payment based on Resource Based Relative Value System (RBRVS)
-Capitation
-Case rates
The four value-based payment models include the following - correct answer --Bundled
payment
-RiskSharing
-Patient-Centered Medical Home/Guided Care
-Pay for Performance
Healthcare financial leaders should focus on initiatives that will help them increase their
organization's revenue/profit/ margins, such as: - correct answer --Payment policing and
standardization of contract requirements.
-Contract performance modeling.
PAYMENT REP-CSPR 2025/ 2026
QUESTIONS WITH VERIFIED
ANSWERS
Medicare Outpatient Observation Notice (MOON) - correct answer --requires hospitals and
Critical Access Hospitals (CAH) to provide notification to individuals receiving observation
services as outpatients for more than 24 hours explaining the status of the individual as an
outpatient, not an inpatient, and the implications of such status.
-Requirements - The MOON must be provided no later than 36 hours after observation services
are initiated or, if sooner, upon release. An oral explanation of the MOON must be provided,
ideally in conjunction with the delivery of the notice, and a signature must be obtained from the
individual, or a person acting on such individual's behalf, to acknowledge receipt. In cases
where such individual or person refuses to sign the MOON, the staff member of the hospital or
CAH providing the notice must sign the notice to certify that notification was presented.
Advanced Beneficiary Notice (ABN): Potential Service Denials - correct answer -Although
typically covered by Medicare, the following services are likely to be denied for lack of medical
necessity under the circumstances described below:
-Lab Tests - Lab tests (for example, complete blood count) when the diagnosis code does
not support Medicare's definition of medical necessity.
-Pap Smear - A screening Pap smear and pelvic exam given more often than every two years,
unless the beneficiary is in a category for which annual exams are covered
-Screening Fecal Occult Blood Test - A screening fecal occult blood test given more often
than annually or if the beneficiary is younger than 50 years
-Screening flexible sigmoidoscopy - A screening flexible sigmoidoscopy given more often
,than every four years or if the beneficiary is younger than 45 years
-Prostate Cancer Screening - A prostate cancer screening test given more often than
annually or if the beneficiary is younger than 50 years
-Tetanus vaccine - A tetanus vaccine given prophylactically (as compared to one given
because the patient stepped on a rusty nail)
-Local Medical Review Policy (LMRP) - Any service that does not meet the coverage criteria
established in Local Medical Review Policy (LMRP). Some Medicare carriers have established
specific coverage criteria. For example, some carriers have established LMRPs for common
office procedures such as removal of benign skin lesions. You can find LMRPs through the
website of your local Medicare carrier.
The various regulatory agencies in the healthcare industry include the following: - correct
answer --Centers for Medicare and Medicaid Services (CMS)
-Federal Trade Commission (FTC)
-Internal Revenue Service (IRS)
-Office of the Inspector General (OIG)
-Department of Justice (DOJ)
-Securities and Exchange Commission (SEC)
-The U.S. Public Health Service (PHS)
Managed Medicare enrollees now enjoy patient protections such as the following: - correct
answer -a) Information disclosure
b) Choice of providers and plans
c) Access to emergency services
d) Participation in treatment decisions
,e) Financial disclosure
f) Respect and nondiscrimination
g) Confidentiality of health information
h) Complaints and appeals
Tiering - correct answer -Tiering can be thought of as the ranking or classifying of one or more
of the provider
delivery system components or benefit design components of a typical managed care plan
to influence choice.
Tiered Provider Networks - correct answer --Delivery network tiering is an effort by insurers to
rein in costs and to address calls from employers and the public for improved quality.
-Tiered networks were first introduced after the cost-cutting success of tiered pharmacy plans
and formularies
Steps used to control costs of managed care include the following: - correct answer --One step -
For the payer and provider to agree on reasonable payment for each service. In general, this
payment arrangement results in payment rates that are beneath the rates that a provider would
charge to an uninsured individual.
-A next step - Might include combining services that are typically provided in conjunction with
one another and bundling the associated charges and determining an appropriate charge for
that set of services or type of care.
-Further efforts - Might include making advance payment to providers for all services needed to
care for a member. This form of payment is referred to as capitation, or per capita payment.
, The basic reimbursement methodologies used for hospital services include the following: -
correct answer --Percent-of-charge payments - A negotiated percentage off of billed charges
and can be applied to any or all of the services that the hospital provides.
-Per diem payments - Refers to a fixed amount per patient per inpatient day.
-Case rate payments - Represent a fixed price for specified care by paying an agreed-upon rate
for a specific healthcare service.
-Carve-outs - Sometimes refer to specific benefits or services that are administered separately
from the rest of the managed care plan and that may be managed by other third parties.
Professional services reimbursement methodologies include the following: - correct answer --
Discountsbasednegotiatedfeeschedules
-Payment based on Resource Based Relative Value System (RBRVS)
-Capitation
-Case rates
The four value-based payment models include the following - correct answer --Bundled
payment
-RiskSharing
-Patient-Centered Medical Home/Guided Care
-Pay for Performance
Healthcare financial leaders should focus on initiatives that will help them increase their
organization's revenue/profit/ margins, such as: - correct answer --Payment policing and
standardization of contract requirements.
-Contract performance modeling.
