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CSPR - Certified Specialist Payment Rep (HFMA) | NEWEST | With complete solution | Updated
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CSPR - Certified Specialist Payment Rep (HFMA) | NEWEST | With complete solution | Updated
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CSPR - Certified Special ist Payment Rep (HFMA) | NEWEST | With complete solution | Updated Steps IIused IIto IIcontrol IIcosts IIof IImanaged IIcare IIinclude: II- II II II IIBundled IIcodes Capitation II Payer IIand IIProvider IIto IIagree IIon IIreasonable IIpayment DRG IIis IIused IIto IIclassify II- II II II IIInpatient IIadmissions IIfor IIthe IIpurpose IIof IIreimbursing IIhospitals IIfor IIeach IIcase IIin IIa IIgiven IIcategory IIw/a IInegotiated IIfixed IIfee, IIregardless IIof IIthe IIactual IIcosts IIincurred Identify IIthe IIvarious IItypes IIof IIprivate IIhealth IIplan IIcoverage II- II II II IIHMO Conventional PPO IIand IIPOS HDHP/SO IIplans II- IIhigh-deductible IIhealth IIplans IIwith IIa IIsavings IIoption; IIPrivate II- IIInclude IIhigher IIpatient IIout-of-pocket IIexpenditures IIfor IItreatments IIthat IIcan IIserve IIto IIreduce IIutilization/costs. Managed IIcare IIorganizations II(MCO) IIexist IIprimarily IIin IIfour IIforms: II- II II II IIHealth IIMaintenance IIOrganizations II(HMO) Preferred IIProvider IIOrganizations II(PPO) Point IIof IIService II(POS) IIOrganizations Exclusive IIProvider IIOrganizations II(EPO) Identify IIthe IIvarious IItypes IIof IIgovernment ‐sponsored IIhealth IIcoverage: II- II II II IIMedicare II- IIGovernment; IIBene ficiaries IIenrolled IIin IIsuch IIplans, IIbut, IIparticipation IIin IIthese plans IIis IIvoluntary. Medicaid Medicaid IIManaged IICare II- IIMedicaid IIbeneficiaries IIare IIrequired IIto IIselect IIand IIenroll IIin IIa IImanaged IIcare IIplan. Medicare IIManaged IICare II(a.k.a. IIMedicare IIAdvantage IIPlans) Identify IIsome IIkey IIdrivers IIof IIincreasing IIhealthcare IIcosts II- II II II IIDemographics Chronic IIConditions Provider IIpayment IIsystems II- IIProvider IIpayment IIsystems IIthat IIare IIdesigned IIto IIreward IIvolume IIrather IIthan IIquality, IIoutcomes, IIand IIprevention Consumer IIPerceptions Health IIPlan IIpressure Physician IIRelationships Supply IIChain Health IIMaintenance IIOrganizations II(HMO) II- II II II IIReferrals PCP Patients IImust IIuse IIan IIin-network IIprovider IIfor IItheir IIservices IIto IIbe IIcovered. Reimbursement II- IImajority IIof IIservices IIoffered IIare IIreimbursed IIthrough IIcapitation IIpayments II(PMPM) Medicare IIis IIcomposed IIof IIfour IIparts: II- II II II IIPart IIA II- IIprovides IIinpatient/hospital, IIhospice, IIand IIskilled IInursing IIcoverage Part IIB II- IIprovides IIoutpatient/medical IIcovera ge Part IIC II- IIan IIalternative IIway IIto IIreceive IIyour IIMedicare IIbenefits II(known IIas IIMedicare Advantage) Part IID II- IIprescription IIdrug IIcoverage HMO IIAct IIof II1973 II- II II II IIThe IIHMO IIAct IIof II1973 IIgave IIfederally IIqualified IIHMOs IIthe IIright IIto IImandate IIthat IIemployers IIoffer IItheir IIprodu ct IIto IItheir IIemployees IIunder IIcertain IIconditions. IIMandating IIan IIemployer IImeant IIthat IIemployers IIwho IIhad II25 IIor IImore IIemployees IIand IIwere IIfor‐profit IIcompanies IIwere IIrequired IIto IImake IIa IIdual IIchoice IIavailable IIto IItheir IIemployees. Which IIof IIthe IIfollowing IIstatements IIregar ding IIemployer -based IIhealth IIinsurance IIin IIthe IIUnited IIStates IIis IItrue? II- II II II IIThe IIreal IIadvent IIof IIemployer -based IIinsurance IIcame IIthrough IIBlue IICross, IIwhich IIwas IIstarted IIby IIhospital IIassociations IIduring IIthe IIDepression. The IIHealth IIMaintenance IIOrganization II(HMO) IIAct IIof II1973 IIgave IIqualified IIHMOs IIthe IIright IIto II"mandate" IIan IIemployer IIunder IIcertain IIconditions, IImeaning IIemployers: II- II II II IIWould IIhave IIto IIoffer IIHMO IIplans IIalong IIside IItraditional IIfee-for-service IImedical IIplans. Which IIof IIthe IIfollowing IIis IIan IIanticipated IIchange IIin IIthe IIrelationships IIbetween IIconsumers IIand IIproviders? II- II II II IIProviders IIwill IIface IImany IInew IIservice IIdemands IIand IIconsumers IIwill IIhave IIvirtually IIunfettered IIaccess IIto IIthose IIservices What IItransition IIbegan IIas IIa IIresult IIof IIthe IIMarch II2010 IIhealthcare IIreform IIlegislation? II- II II II IIA IItransition IItoward IInew IImodels IIof IIhealth IIcare IIdelivery IIwith IIcorresponding IIchanges IIsystem IIfinancing IIand IIprovider IIreimbursement. Which IIstatement IIis IIfalse IIconcerning IIABNs? II- II II II IIABN IIbegan IIestablishing IInew IIrequirements IIfor IImanaged IIcare IIplans IIparticipating IIin IIthe IIMedicare IIprogram. Which IIStatement IIis IITRUE IIconcerning IIABNs? II- II II II II-ABNs IIare IInot IIrequired IIfor IIservices IIthat IIare IInever IIcovered IIby IIMedicare. -An IIABN IIform IInotifies IIthe IIpatient IIbefore IIhe IIor IIshe IIreceives IIthe IIservice IIthat IIit IImay IInot IIbe covered IIby IIMedicare IIand IIthat IIhe IIor IIshe IIwill IIneed IIto IIpay IIout IIof IIpocket. -Although IIABNs IIcan IIhave IIsignificant IIfinancial IIimplications IIfor IIthe IIphysician, IIthey IIalso serve IIan IIimportant IIfraud IIand IIabuse IIcompliance IIfunction. What IIis IIthe IIoverall IIfunction IIof IIMedicaid? II- II II II IIThe IIpay IIfor IImedical IIassistance IIfor IIcertain IIindividuals IIand IIlow-income IIfamilies Medical IICost IIRatio II(MCR) IIor IIMedical IILoss IIRatio II(MLR) IIis IIdefined IIas: II- II II II IITotal IIMedical IIExpenses IIdivided IIby IITotal IIPremiums Provider IIservice IIorganizations II(PSOs) IIfunction IIlike IIhealth IImaintenance IIorganizations II(HMOs) IIin IIall IIof IIthe IIfollowing IIways, IIEXCEPT: II- II II II IITies IIto IIthe IIhealthcare IIdelivery IIindustry IIrather IIthan IIthe IIinsurance IIindustry Provider IIservice IIorganizations II(PSOs) IIfunction IIlike IIhealth IImaintenance IIorganizations II(HMOs) IIin IIall IIof IIthe IIfollowing IIways: II- II II II II-Risk IIpooling -Capitalization -Network IImanagement Which IIof IIthe IIfollowing IIis IIa IIservice IIprovided IIby IIa IIwell-managed IIthird-party IIadministrator II(TPA)? II- II II II II-Administrative -Utilization IIreview II(UR) II -Claims IIprocessing What IIis IItiering? II- II II II IIThe IIranking IIor IIclassifying IIof IIone IIor IImore IIof IIthe IIprovider IIdelivery IIsystem IIcomponents Which IIoption IIis IIa IIpractice IIused IIto IIcontrol IIcosts IIof IImanaged IIcare? II- II II II II-Making IIadvance IIpayment IIto IIproviders IIfor IIall IIservices IIneeded IIto IIcare IIfor IIa IImember -Combin ing IIservices IIprovided IIand IIbundling IIthe IIassociated IIcharges -Agreement IIbetween IIthe IIpayer IIand IIprovider IIon IIreasonable IIpayment IIfor IIeach IIservice. Which IIoption IIis IIa IIrisk IIinvolved IIin IIper IIdiem IIpayments? II- II II II II-The IIrisk IIto IIthe IIinsurance IIcompany IIor IIhealth IIplan -The IIrisk IIto IIthe IIhospital -The IIrisk IIwhen IIembracing IIper IIdiem IIpayments IIin IIcomplex IIcase Diagnosis -related IIgroup II(DRG) IIis: II- II II II IIA IIpayment IIcategory How IIis IIthe IIterm IIcarve -out IIused IIwhen IIdiscussing IImanaged IIcare? II- II II II IITo IIrefer IIto IIspecific IIbenefits IIor IIservices What IIis IIthe IIterm IICoordination IIof IIBenefits II(COB)? II- II II II IIA IIterm IIused IIto IIdescribe IIhow IIpayment IIis IIcoordinated IIfor IIpatients IIwho IIhave IIcoverage IIthrough IItwo IIinsurance IIpolicies Which IIthree IIcomponents IIare IIused IIto IIdetermine IIthe IItotal IIRVU IIvalue IIfor IIa IIservice? II- II II II II-Malpractice IIexpense -Lowest IImarket IIprice IIfor IIservices IIused II -Medicare IIdiscounts
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