CSPR - Certified Specialist Payment Rep (HFMA) Questions and Answers

CSPR - Certified Specialist Payment Rep (HFMA) Questions and Answers

1. Steps used to control costs of managed care include:: Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
2. 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
3. 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.
4. 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)
5. Identify the various types of governmentsponsored 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)
6. 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
7. 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)



, CSPR - Certified Specialist Payment Rep (HFMA) Questions and Answers

8. 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
9. 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.
10. Which of the following statements regarding employer-based health insur-
ance 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.
11. 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.
12. Which of the following is an anticipated change in the relationships be-
tween consumers and providers?: Providers will face many new service demands
and consumers will have virtually unfettered access to those services
13. What transition began as a result of the March 2010 healthcare reform leg-
islation?: A transition toward new models of health care delivery with corresponding
changes system financing and provider reimbursement.
14. Which statement is false concerning ABNs?: ABN began establishing new
requirements for managed care plans participating in the Medicare program.
15. Which Statement is TRUE concerning ABNs?: -ABNs are not required for
services that are never covered by Medicare.
-An ABN form notifies the patient before he or she receives the service that it may
not be
covered by Medicare and that he or she will need to pay out of pocket.
-Although ABNs can have significant financial implications for the physician, they
also
serve an important fraud and abuse compliance function.
16. What is the overall function of Medicaid?: The pay for medical assistance for
certain individuals and low-income families
17. Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as:: Total
Medical Expenses divided by Total Premiums


, CSPR - Certified Specialist Payment Rep (HFMA) Questions and Answers

18. Provider service organizations (PSOs) function like health maintenance or- X2 X2 X2 X2 X2 X2 X2 X2




ganizations(HMOs)inall of the followingways,EXCEPT:: Ties to the healthcare deli
X2 X2 X2 X2 X2 X2 X2 X2 X
2 X2 X2 X2 X2 X2




very industry rather than the insurance industry
X2 X2 X2 X2 X2 X2




19. Provider service organizations (PSOs) function like health maintenance or X2 X2 X2 X2 X2 X2 X2 X2




ganizations (HMOs) in all of the following ways:: -Risk pooling X2 X2 X2 X2 X2 X2 X2 X2 X2




-Capitalization
-Network management X2




20. Which of the following is a service provided by a well-managed third- X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2




party administrator (TPA)?: -Administrative X2 X2 X2




-Utilization review (UR) X2 X2




-Claims processing X2




21. What is tiering?: The ranking or classifying of one or more of the provider deli
X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2




very system components X2 X2




22. Whichoptionis a practice usedtocontrol costsof managedcare?: - X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2




Making advance payment to providers for all services needed to care for a member
X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2




-Combining services provided and bundling the associated charges X2 X2 X2 X2 X2 X2 X2




-Agreement between the payer and provider on reasonable payment for each service. X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2




23. Which option is a risk involved in per diem payments?: - X2 X2 X2 X2 X2 X2 X2 X2 X2 X2




The risk to the insurance company or health plan
X2 X2 X2 X2 X2 X2 X2 X2




-The risk to the hospital X2 X2 X2 X2




-The risk when embracing per diem payments in complex case
X2 X2 X2 X2 X2 X2 X2 X2 X2




24. Diagnosis-related group (DRG) is:: A payment category X2 X2 X2 X2 X2 X2




25. How is the term carve- X2 X2 X2 X2




out used when discussing managed care?: To refer to specific benefits or services
X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2




26. What is the term Coordination of Benefits (COB)?: A term used to describe hoX2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2




w payment is coordinated for patients who have coverage through two insurance policie
X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2




s
27. Which three components are used to determine the total RVU value for a ser X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2




vice?: -Malpractice expense X2 X2




-Lowest market price for services used X2 X2 X2 X2 X2




-Medicare discounts X2




28. A fixed payment amount based upon the number of members assigned to apr
X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X
2




ovider,and does not vary based upon the number of services rendered,is known a
X
2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X
2 X2 X2




s:: Capitation X2




29. Aligning incentives has come to mean X2 X2 X2 X2 X2 X2




.:Theappropriateaddition of some risk in the exchange of health care to a patient for
X
2 X
2 X
2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2 X2




some form of remunera- tion. X2 X2 X2 X2