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CSPR CERTIFICATION EVALUATION 2026
EXAM SCRIPT FULLY SOLVED QUESTION
SET
◉ACA. Answer: Affordable Care Act ◉HMO (Health Maintenance Organization). Answer: The organization is both the insurer and provider of a set of defined services. Patients within this network must use an in-network provider for their services to be covered. ◉Capitation Payment. Answer: part of prospective payment in which healthcare providers receive fixed monthly payments for services rendered regardless of whether or not services are used ◉PPO (Preferred Provider Organization). Answer: A network of healthcare providers, such as hospitals and physicians. They have entered into a contract with a third-party entitled to deliver healthcare services to individuals covered under the plan. ◉POS. Answer: Combines the features of both an HMO and PPO, with costs for covered persons falling somewhere between the two.
Required to have a PCP, but can self refer to other in-network specialists. ◉EPO. Answer: Services are covered only if patients use doctors, specialists or hospitals in the plan's network. There are no out of network benefits. ◉ACO. Answer: Accountable Care Organization ◉What employer-based insurance was first?. Answer: Blue Cross ◉ERISA (Employee Retirement Income Security Act). Answer: Federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans. ◉Government health Coverage Examples. Answer: Medicare and Medicaid ◉Medicare Managed Care Plans. Answer: These plans charge a monthly premium and a small copayment for each office visit, but not a deductible. Like private payer managed care plans, these plans often require patients to use a specific network of physicians, hospitals, and facilities. Some plans offer the option of receiving services from providers outside the network for a higher fee.
◉Centers for Medicare and Medicaid Services (CMS). Answer: Administers all federally supported healthcare financing programs ◉Federal Trade Commission (FTC). Answer: Examines mergers of hospitals and other healthcare institutions ◉Section 501(c)3. Answer: Grants tax-exempt status and monitors compliance with legislation. ◉Office of the Inspector General (OIG). Answer: Investigates organizations for violations of the Medicare and Medicaid anti- kickback statute. ◉Department of Justice (DOJ). Answer: Prosecutes healthcare fraud under various federal criminal statutes. ◉US Public Health Service. Answer: Promotes the protection and advancement of the nation's physical and mental health. ◉Securities and Exchange Commission (SEC). Answer: Enforces the newly passed securities laws and promotes stability in the markets
◉Balanced Budget Act of 1997 Objectives. Answer: Decrease Medicare reimbursement levels, Mandate an end to the most areas of cost-based reimbursement and Medicare Part C plans ◉Inpatient Prospective Payment System (IPPS). Answer: system in which Medicare reimburses hospitals for inpatient hospital services according to a predetermined rate for each discharge. ◉Outpatient Prospective Payment System (OPPS). Answer: The Medicare prospective payment system used for hospital-based outpatient services and procedures that is predicated on the assignment of ambulatory payment classifications ◉Medicare Payments to Physicians. Answer: Part B ◉Purpose of Medicare Value Based purchasing (VBP) programs. Answer: Provides differential payments to physicians based on the quality of care provided ◉MSPQ. Answer: Questions to be asked to patients in order to help determine if Medicare is primary or secondary for the patient's service that is about to be provided.
◉Overall function of Medicaid. Answer: Pay for medical assistance for certain individuals and low-income families ◉Medical Loss Ratio (MLR). Answer: The difference of healthcare costs to revenue received. Calculated as total medical expense divided by total revenue. ◉Provider-sponsored organization (PSO). Answer: Type of point-of- service plan in which the physicians that practice in a regional or community hospital organize the plan ◉Cost Sharing. Answer: Provision of a healthcare insurance policy that requires policyholders to pay for a portion of their healthcare services; a cost-control mechanism. ◉Gatekeeper. Answer: a primary care provider who refers patients to other providers for services he or she cannot perform ◉Deductible. Answer: Flat dollar amounts paid by an enrollee before benefits apply ◉High Deductible Health Plan (HDHP). Answer: A plan that requires individuals to pay a higher deductible to cover medical expenses before insurance plan payments begin; chosen to save money on premiums.
◉Co-insurance. Answer: A provision in the member's coverage that limits the amount of coverage by the plan to a certain percentage, commonly 80% ◉Copayment. Answer: A provision under which the insured pays a flat dollar amount each time a covered medical service is received ◉Stop Loss. Answer: A provision under which an insured pays a certain amount, after which the insurance company pays 100 percent of the remaining covered expenses. ◉coordination of benefits. Answer: A provision that helps determine the primary payer in situations where an insured is covered by more than one policy, thus avoiding claims overpayments. ◉Out of Pocket maximum. Answer: The dollar limit set on the total amount of covered charges that will be paid by the enrolee. ◉Percent of Pay. Answer: A rarely used share of cost structure in which employees out of pocket costs are fixed as percentages of a respective employee's salary. ◉tiered provider networks. Answer: health insurance products that group providers into tiers based on the cost or efficiency of care they
◉APCs. Answer: Ambulatory Payment Classifications ◉Carve-outs. Answer: Sometimes refer to specific benefits or services that are administered separately from the rest of the managed care plan and that may be managed by other third parties. ◉Percentage of Charge Payments. Answer: A negotiated percentage off of billed charges can be applied to any or all the services that the hospital provides ◉TRICARE Prime. Answer: The basic managed care health plan offered by TRICARE ◉TRICARE Standard. Answer: The fee-for-service health plan offered by TRICARE. ◉TRICARE. Answer: military health plan that provides services for active duty personnel and their families, survivors of military personnel and retired military personnel and their families ◉RBRVS (Resource Based Relative Value Scale). Answer: national fee system used to calculate the approved amount for Medicare payments
◉Components used to determine the total RVU. Answer: Years of experience, Lowest market price for services, Medicare discounts ◉Capitation provider obligations. Answer: Understand costs of care, accept risks, develop an appropriate data and system set, operational/financial, clinical infrastructure, stop loss ◉Aligning incentives. Answer: The appropriate addition of some risk in the exchange of health care to a patient for some form of remuneration. ◉appropriate care. Answer: Right amount of Care was provided, setting usually means the least intensive setting required, time usually refers to medical intervention at the earliest possible time to prevent a bad situation, most appropriate cost ◉Fee-for-service (FFS). Answer: set of fees established by a health care provider and paid for by the patient ◉per diems. Answer: Daily flat rate payment for whatever care is provided that day. ◉value based payment models. Answer: Payment made to providers based on measures including quality, efficiency, cost, and positive patient experience
◉Bundled Payment. Answer: The reimbursement of providers on the basis of expected costs for clinically defined episodes of care ◉Pay for Performance. Answer: Pay providers based on the achievement of preset quality and performance measures ◉MCG Guidelines. Answer: Evidence based Care Guidance for payers and providers ◉Prospective performance. Answer: Modeling is critical during the negotiation to ensure an acceptable and successful outcome. ◉Retrospective Performance. Answer: Modeling evaluates the effectiveness of the terms negotiated and clarifies the profitability of each contract after the agreement is signed. ◉Volume Risk. Answer: The primary objectives of payers are to rein in costs, create cost predictability to price premiums and publish prices for common procedures, forcing hospitals to accept lower payments ◉Cost Risk. Answer: Payers are shifting cost risk to hospitals with risk based arrangements.
◉CDHP (consumer driven health plan). Answer: Plans that try to pass decision making onto you, employer gives money you spend decision making is put on you, employers money given to you to spend, pay full price ◉Rating tiers. Answer: Different rates charged on the basis of the number and relationships ◉Conversion Factor. Answer: Multiplying the percentage in each tier by the number of people actually estimated to be covered, and dividing that by the percentage times the cost factor produces a premium weighting factor ◉Case management trends. Answer: Greater physician involvement, Reduction of administrative costs, shift from broad-based toward more focused efforts ◉Utilization management techniques. Answer: Prospective, concurrent and retrospective tools to control the costs of providing healthcare services to enrollees ◉Concurrent review. Answer: Managing care during the course of an inpatient admission, with the goal of more efficient inpatient care
◉Clinical Staff. Answer: Must be familiar with payer requirements for appropriate documentation of medical necessity and protocols for pre-authorizations. ◉Practice Manager. Answer: Oversee all operation aspects of the practice, including managed care contracting ◉Registration Staff. Answer: Assist with eligibility verification and accurate entry of patient insurance information into the practice management or billing system. ◉Physician Leader. Answer: Provide input to the practice manager regarding expected/target reimbursement rates. ◉Electronic Data Interchange (EDI). Answer: Exchange of computerized data in a standardized format allowing healthcare providers and payers to exchange common information ◉UB04 (CMS 1450). Answer: The claim form submitted for inpatient and outpatient hospital, critical access hospital (CAHs) and comprehensive outpatient rehab facilities (CORFs). 837I ◉CMS-1500. Answer: most common health insurance claim form used to file claims for physicians' services 837P
◉Required for claims processing. Answer: Name, ID, Gender, Age, DX, DOS ◉EOB - Explanation of Benefits. Answer: A statement sent by a third- party payer to the patient to explain services provided, amounts billed, and payments made by health plans ◉COB - coordination of benefits. Answer: Management of payment between two or more third-party payers for a service ◉claims adjudication. Answer: Term used in the insurance industry for the process of paying or denying claims based on the patient's plan/coverage ◉Patient Bill of Rights. Answer: Established in 1973, a list of rights that are designed to protect both the patient and HCP ◉Leapfrog Group. Answer: Organization that promotes healthcare safety by giving consumers the information they need to make better-informed choices about the hospitals they choose ◉HSA - health savings account. Answer: An account used in association with a medical plan that carries a high deductible
◉Recovery Audit Contractor (RAC). Answer: A 3rd-party entity working under the direction of CMS to detect improper Medicare payments through review of providers' medical records an Medicare claims data ◉DNV GL. Answer: Accreditation utilizing the ISO 9001 quality management system that emphasizes continual improvement and requires an annual onsite survey. A hospital must be certified to the ISO 9001 requirements within two years of its initial accreditation. ◉The Joint Commission (TJC). Answer: A United States-based nonprofit tax-exempt 501(c) organization that accredits more than 20,000 health care organizations and programs in the United States. ◉HMO Solvency. Answer: Financial guidelines that the act established primarily to protect consumers from the bankruptcy of HMOs ◉NAIC - National Association of Insurance Commissioners. Answer: An organization composed of insurance commissioners from all 50 states, the District of Columbia and the 4 U.S territories, formed to resolve insurance regulatory issues. ◉Prompt payment laws. Answer: State laws that mandate a time period within which clean claims must be paid; if they are not, financial penalties are levied against the payer
◉Credentials verification organization (CVO). Answer: Ensures a meaningful, rigorous and fair credentialing process that protects both patients and providers from poor credentialing practices. ◉Health Network. Answer: Provides a comprehensive assessment covering network management quality management and improvement, prover credentialing and member protection ◉Health UM. Answer: Ensures that appropriately trained clinical personnel conduct and oversee the utilization review process. ◉HIPAA Security Accreditation. Answer: Completes a comprehensive quality and regulatory accreditation regimen for information and data delivery across multiple systems and technology platforms. ◉HIPAA Title I. Answer: Affects covered entities, including group health plans, healthcare providers, health insurance plans, and healthcare clearinghouses, as well as most employers that provide employee health benefits. ◉HIPAA Title II. Answer: Provides rights for the transfer of electronic health care data. Administration and Simplification
