CSPR - Certified Specialist Payment Rep (HFMA)
questions with correct answers
Steps used to control costs of Bundled codes
managed care Capitation
include: Payer and Provider to agree on reasonable payment
Inpatient admissions for the purpose of reimbursing
hospitals for each case in a given category w/a
DRG is used to classify
negotiated fixed fee, regardless of the actual costs
incurred
HMO
Conventional PPO
Identify the various types of and POS
private health plan coverage 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.
Health Maintenance Organizations (HMO)
Managed care
Preferred Provider Organizations (PPO) Point
organizations (MCO) exist
of Service (POS) Organizations
primarily in four forms:
Exclusive Provider Organizations (EPO)
Medicare - Government; Beneficiaries enrolled in such
plans, but, participation in these
plans is voluntary.
Identify the various types of
Medicaid
government‐sponsored health
Medicaid Managed Care - Medicaid beneficiaries are required
coverage:
to select and enroll in a managed care plan. Medicare
Managed Care (a.k.a. Medicare Advantage Plans)
questions with correct answers
Steps used to control costs of Bundled codes
managed care Capitation
include: Payer and Provider to agree on reasonable payment
Inpatient admissions for the purpose of reimbursing
hospitals for each case in a given category w/a
DRG is used to classify
negotiated fixed fee, regardless of the actual costs
incurred
HMO
Conventional PPO
Identify the various types of and POS
private health plan coverage 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.
Health Maintenance Organizations (HMO)
Managed care
Preferred Provider Organizations (PPO) Point
organizations (MCO) exist
of Service (POS) Organizations
primarily in four forms:
Exclusive Provider Organizations (EPO)
Medicare - Government; Beneficiaries enrolled in such
plans, but, participation in these
plans is voluntary.
Identify the various types of
Medicaid
government‐sponsored health
Medicaid Managed Care - Medicaid beneficiaries are required
coverage:
to select and enroll in a managed care plan. Medicare
Managed Care (a.k.a. Medicare Advantage Plans)
