CSPR - CERTIFIED SPECIALIST PAYMENT REP
(HFMA) 2024 ACTUAL EXAM COMPLETE 350
QUESTIONS WITH DETAILED VERIFIED ANSWERS
(100% CORRECT ANSWERS) /ALREADY GRADED A
Steps used to control costs of managed care include: - answer-Bundled codes
b b b b b b b b b b b
Capitation b
Payer and Provider to agree on reasonable payment
b b b b b b b
DRG is used to classify - answer-Inpatient admissions for the purpose of reimbursing
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b hospitals for each case in a given category w/a negotiated fixed fee, regardless of the
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b actual costs incurred
b b
Identify the various types of private health plan coverage - answer-HMO
b b b b b b b b b b
Conventional
PPO and POS
b b
HDHP/SO plans - high-deductible health plans with a savings option; Private - Include
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b higher patient out-of-pocket expenditures for treatments that can serve to reduce
b b b b b b b b b b
b utilization/costs.
,Managed care organizations (MCO) exist primarily in four forms: - answer-Health
b b b b b b b b b b
b Maintenance Organizations (HMO) b b
Preferred Provider Organizations (PPO)
b b b
Point of Service (POS) Organizations
b b b b
Exclusive Provider Organizations (EPO)
b b b
Identify the various types of government‐sponsored health coverage: - answer-Medicare -
b b b b b b b b b b
b Government; Beneficiaries enrolled in such plans, but, participation in these
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plans is voluntary.
b b
Medicaid
Medicaid Managed Care - Medicaid beneficiaries are required to select and enroll in a
b b b b b b b b b b b b b
b managed care plan. b b
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
b b b b b b
Identify some key drivers of increasing healthcare costs - answer-Demographics
b b b b b b b b b
Chronic Conditions
b
Provider payment systems - Provider payment systems that are designed to reward
b b b b b b b b b b b
b volume rather than quality, outcomes, and prevention
b b b b b b
Consumer Perceptions b
Health Plan pressure
b b
Physician Relationships b
Supply Chain b
,Health Maintenance Organizations (HMO) - answer-Referrals
b b b b b
PCP
Patients must use an in-network provider for their services to be covered.
b b b b b b b b b b b
Reimbursement - majority of services offered are reimbursed through capitation
b b b b b b b b b
b payments (PMPM) b
Medicare is composed of four parts: - answer-Part A - provides inpatient/hospital,
b b b b b b b b b b b
b hospice, and skilled nursing coverage
b b b b
Part B - provides outpatient/medical coverage
b b b b b
Part C - an alternative way to receive your Medicare benefits (known as Medicare
b b b b b b b b b b b b b
Advantage)
Part D - prescription drug coverage
b b b b b
HMO Act of 1973 - answer-The HMO Act of 1973 gave federally qualified HMOs the right
b b b b b b b b b b b b b b b
b to mandate that employers offer their product to their employees under certain
b b b b b b b b b b b
b conditions. Mandating an employer meant that employers who had 25 or more employees
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b and were for‐profit companies were required to make a dual choice available to their
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b employees.
Which of the following statements regarding employer-based health insurance in the
b b b b b b b b b b
b United States is true? - answer-The real advent of employer-based insurance came
b b b b b b b b b b b
b through Blue Cross, which was started by hospital associations during the Depression.
b b b b b b b b b b b
, The Health Maintenance Organization (HMO) Act of 1973 gave qualified HMOs the right to
b b b b b b b b b b b b b
b "mandate" an employer under certain conditions, meaning employers: - answer-Would
b b b b b b b b b
b have to offer HMO plans along side traditional fee-for-service medical plans.
b b b b b b b b b b
Which of the following is an anticipated change in the relationships between consumers
b b b b b b b b b b b b
b and providers? - answer-Providers will face many new service demands and consumers
b b b b b b b b b b b
b will have virtually unfettered access to those services
b b b b b b b
What transition began as a result of the March 2010 healthcare reform legislation? -
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b answer-A transition toward new models of health care delivery with corresponding
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b changes system financing and provider reimbursement.
b b b b b
Which statement is false concerning ABNs? - answer-ABN began establishing new
b b b b b b b b b b
b requirements for managed care plans participating in the Medicare program.
b b b b b b b b b
Which Statement is TRUE concerning ABNs? - answer--ABNs are not required for services
b b b b b b b b b b b b
b that are never covered by Medicare.
b b b b b
-An ABN form notifies the patient before he or she receives the service that it may not be
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covered by Medicare and that he or she will need to pay out of pocket.
b b b b b b b b b b b b b b
-Although ABNs can have significant financial implications for the physician, they also
b b b b b b b b b b b
serve an important fraud and abuse compliance function.
b b b b b b b
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