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CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) EXAM WITH ANSWERS GRADED A+ $10.49   Add to cart

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CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) EXAM WITH ANSWERS GRADED A+

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CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) EXAM WITH ANSWERS GRADED A+ 1. Steps used to control costs of managed care include: Bundled codes Capitation Payer and Provider to agree on reasonable pay- ment 2. DRG is used to classify Inpatient admissions for the purpose of reimburs- ing ...

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  • September 25, 2024
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  • CSPR - CERTIFIED SPECIALIST PAYMENT REP
  • CSPR - CERTIFIED SPECIALIST PAYMENT REP
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CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) EXAM WITH
ANSWERS GRADED A+
1. Steps used to control Bundled codes
costs of managed care Capitation
include: Payer and Provider to agree on reasonable pay-
ment

2. DRG is used to classify Inpatient admissions for the purpose of reimburs-
ing hospitals for each case in a given category w/a
negotiated fixed fee, regardless of the actual costs
incurred

3. Identify the various HMO
types of private health Conventional
plan coverage PPO and POS
HDHP/SO plans - high-deductible health plans
with a savings option; Private - Include higher pa-
tient out-of-pocket expenditures for treatments that
can serve to reduce utilization/costs.

4. Managed care organi- Health Maintenance Organizations (HMO)
zations (MCO) exist pri- Preferred Provider Organizations (PPO)
marily in four forms: Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)

5. Identify the various Medicare - Government; Beneficiaries enrolled in
types of governmen- such plans, but, participation in these
t sponsored health covp- lans is voluntary.
erage: Medicaid
Medicaid Managed Care - Medicaid beneficiaries
are required to select and enroll in a managed care
plan.
Medicare Managed Care (a.k.a. Medicare Advan-
tage Plans)

6. Identify some key dri- Demographics
vers of increasing Chronic Conditions
healthcare costs Provider payment systems - Provider payment
systems that are designed to reward volume rather
than quality, outcomes, and prevention
Consumer Perceptions


,CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) EXAM WITH
ANSWERS GRADED A+
Health Plan pressure
Physician Relationships
Supply Chain

7. Health Maintenance Or- Referrals
ganizations (HMO) 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)

8. Medicare is composed Part A - provides inpatient/hospital, hospice, and
of four parts: 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 con-
ditions. Mandating an employer meant that em-
ployers 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 The real advent of employer-based insurance
statements regarding came through Blue Cross, which was started by
employer-based health hospital associations during the Depression.
insurance in the United
States is true?

11. The Health Main- Would have to offer HMO plans along side tradi-
tenance Organization tional fee-for-service medical plans.
(HMO) Act of 1973
gave qualified HMOs
the right to "mandate"
an employer under cer-



, CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) EXAM WITH
ANSWERS GRADED A+
tain conditions, mean-
ing employers:

12. Which of the follow- Providers will face many new service demands
ing is an anticipated and consumers will have virtually unfettered ac-
change in the rela- cess to those services
tionships between con-
sumers and providers?

13. What transition began A transition toward new models of health care de-
as a result of the March livery with corresponding changes system financ-
2010 healthcare reform ing and provider reimbursement.
legislation?

14. Which statement ABN began establishing new requirements for
is false concerning managed care plans participating in the Medicare
ABNs? program.

15. Which Statement is -ABNs are not required for services that are never
TRUE concerning covered by Medicare.
ABNs? -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 im-
plications for the physician, they also
serve an important fraud and abuse compliance
function.

16. What is the overall The pay for medical assistance for certain individ-
function of Medicaid? uals and low-income families

17. Medical Cost Ratio Total Medical Expenses divided by Total Premiums
(MCR) or Medical Loss
Ratio (MLR) is defined
as:

18. Provider service orga- Ties to the healthcare delivery industry rather than
nizations (PSOs) func- the insurance industry
tion like health main-

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