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CSPR CERTIFIED SPECIALIST PAYMENT
REP HFMA 2025 QUESTIONS AND
ANSWERS PROFESSOR VERIFIED
ALREADY GRADED A+
⫸ Medicare provides health insurance benefits to the following: Answer: - All persons age 65 and older
- Individuals with permanent renal (kidney) failure, eligible for dialysis treatment
- Individuals with certain disabilities ⫸ Mcare Part A (Hospital Insurance) Answer: - covers most medically necessary hospital, skilled nursing facility, home health, and hospice care services.
- It is free if you have worked and paid Social Security taxes for at least 40 calendar quarters (10 years); those who have worked and paid taxes for less than 40 calendar quarters (10 years) are required to pay a fee ⫸ Mcare Part B (Medical Insurance) Answer: covers most medically necessary doctors' services, preventive care, durable medical equipment, hospital outpatient services, laboratory tests, x-rays, mental health care, and some home health and ambulance services. An additional monthly premium is paid for this coverage.
⫸ Mcare Part C (Advantage) Answer: - allows private health insurance companies to provide Medicare benefits.
- These Medicare private health plans are known as Medicare Advantage Plans. These plans must offer at least the same benefits as Original Medicare (those covered under Parts A and B) but can do so with different rules, costs, and coverage restrictions.
- Medicare Part C may also offer additional health coverage benefits; you typically obtain Part D as part of a Medicare Advantage benefits package. --You may pay a monthly premium for this coverage, in addition to your Part B premium. ⫸ Mcare Part D (Prescription) Answer: - outpatient prescription drug insurance, was established by the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) on January 1, 2006.
- Part D is provided only through private insurance companies that have contracts with the government—it is never provided directly by the government (like original Medicare is). ⫸ Dual Eligibility Answer: - Dual Eligibility is not a separate benefit, but to be considered dually eligible, persons must enroll in Medicare Part A and/or Medicare Part B. As an alternative to original Medicare (Part A and Part B), persons may opt for Medicare Part C (Medicare Advantage).
- In addition, persons must be enrolled in either full Medicaid or one of Medicaid's Medicare Savings Programs (MSPs).
- Medicare is always the first payer (primary) and Medicaid (secondary) covers the remaining cost, given that the services are Medicaid covered.
⫸ Which statement is false concerning ABNs? Answer: ABN began establishing new requirements for managed care plans participating in the Medicare program. ⫸ Which Statement is TRUE concerning ABNs? Answer: ‐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. ⫸ What is the overall function of Medicaid? Answer: The pay for medical assistance for certain individuals and low‐income families ⫸ Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: Answer: Total Medical Expenses divided by Total Premiums ⫸ Provider service organizations (PSOs) function like health maintenance organizations (HMOs) in all of the following ways, EXCEPT: Answer: Ties to the healthcare delivery industry rather than the insurance industry ⫸ Provider service organizations (PSOs) function like health maintenance organizations (HMOs) in all of the following ways: Answer: ‐Risk pooling ‐Capitalization
‐Network management ⫸ Which of the following is a service provided by a well‐managed third‐party administrator (TPA)? Answer: ‐Administrative ‐Utilization review (UR) ‐Claims processing ⫸ What is tiering? Answer: The ranking or classifying of one or more of the provider delivery system components ⫸ Which option is a practice used to control costs of managed care? Answer: ‐ Making advance payment to providers for all services needed to care for a member ‐Combining services provided and bundling the associated charges ‐Agreement between the payer and provider on reasonable payment for each service. ⫸ Which option is a risk involved in per diem payments? Answer: ‐The risk to the insurance company or health plan ‐The risk to the hospital ‐The risk when embracing per diem payments in complex case ⫸ Diagnosis‐related group (DRG) is: Answer: A payment category
⫸ As the healthcare industry moves to control growth in medical spending, what initiative can help hospitals maintain their margins? Answer: Contract standardization ⫸ As the healthcare industry moves to control growth in medical spending, what initiative can NOT help hospitals maintain their margins? Answer: ‐Pay‐for‐ performance programs ‐Health savings accounts ‐Price transparency ⫸ Identify which initiatives are focused on in an effort to help increase an organization's revenue/profit /margins. Answer: ‐Health plan consolidation ‐Payment policing and standardization of contract requirements ‐Shift in volume and cost risk to hospitals ‐Contract performance modeling ⫸ What are rating tiers? Answer: Different rates charged on the basis of the number and relationships ⫸ What is the role of reinsurance? Answer: Reinsurance seeks to limit a policyholder's liability for catastrophic claims ⫸ Which option is a major trend in case management? Answer: ‐Shift from broad‐based toward more focused efforts ‐Reduction of administrative costs
‐Greater physician involvement ⫸ What type of provider authorization is applied in emergency cases, where prior authorization is impossible? Answer: Concurrent ⫸ What is utilization management (UM)? Answer: A tool to control the costs of providing healthcare services to enrollees ⫸ Which of the following statements is true about disease management (DM)? Answer: DM programs encourage patients to assume some control over their disease state ⫸ What is the function of catastrophic case management (CM)? Answer: It is used to manage diseases in patients with very high costs of care. ⫸ What is demand management? Answer: A coordinated effort by the MCO, employers, and providers to control the utilization of medical services and resources ⫸ All of the following are effective contract evaluation criteria, EXCEPT: Answer: Detailed contract performance assessments ⫸ All of the following are effective contract evaluation criteria: Answer: ‐General payer or provider criteria ‐Reimbursement levels and parameters ‐Provider costs and responsibilities
⫸ Which data is included in a termination provision in standard contracting? Answer: ‐What is cause? ‐What is termination Without Cause? ‐Notice of termination ⫸ What is direct contracting? Answer: A single‐employer or multi‐employer healthcare alliances that contract directly with providers for healthcare services ⫸ What is a non‐directed PPO? Answer: A payer that has contracted either directly or indirectly with the provider to access preferred rates ⫸ All of the following are responsibilities of a provider organization's Board of Directors, EXCEPT: Answer: Implementation issues ⫸ All of the following are responsibilities of a provider organization's Board of Directors: Answer: ‐Fiduciary matters ‐Legal affairs ‐Policy matters ⫸ Which of the following is required for claims processing? Answer: ‐Patient and/or enrollee ID, age, and gender ‐Type of diagnosis/major diagnostic category ‐Date of service
⫸ Which of the following terms refers to information about any other health plan or carrier that may share liability for healthcare expenses via a spouse's coverage or the like? Answer: Coordination of benefits (COB) ⫸ What is the function of electronic data interchange (EDI)? Answer: To allow both healthcare providers and payers to exchange common information required ⫸ What was the aim of advocacy groups initiated in the late 1990s? Answer: To inform the discussion about the quality of care and the value of benefit plans ⫸ Which of the following statements is true regarding The Leapfrog Group? Answer: The Leapfrog Group was started in the late 1990s to engage consumers and clinicians in the discussion to improve care quality. ⫸ Which option is included in the set of new value propositions and tools that emerged in the early 2000s? Answer: ‐Product development focused on employee contribution strategies, network access, and funding options. ‐Medical management philosophies based on retrospective evaluation of care, rather than prospective review and management. ‐A proliferation of self‐service technologies to reduce administrative costs. ⫸ Identify which option(s) is a benefit for CDHP consumers. Answer: ‐Coverage ‐Choice ‐Access
⫸ What is one purpose of the Emergency Medical Treatment and Active Labor Act (EMTALA)? Answer: To govern when and how a patient presenting at a hospital may be refused treatment ⫸ What is the purpose of the URAC? Answer: To promote healthcare quality through accreditation and certification programs ⫸ Which options are a focus of the HIPAA Title II series of laws? Answer: ‐Health care access, portability, and renewability ‐To maintain the efficiency and effectiveness of the electronic transmission of health information. ‐Health care claim professional (837P), health care claim dental (837D), and health care claim payment/advice (835) ⫸ What was the expectation of the 2010 Patient Protection and Affordable Care Act (PPACA)? Answer: To bring coverage to millions of Americans who could not or would not purchase health insurance ⫸ What is Managed Care? Answer: 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)
⫸ HMO Act 1973 Answer: ‐The original HMO Act was designed to create new physician groups that would act as prepaid practice groups (PPGs). ‐HMO concept was to create a seamless integration of comprehensive care delivery with a financing mechanism for benefits. These benefit plans would remove most deductibles and copays, and also cover preventive services that were previously excluded by all insurers ⫸ Effects of the HMO Act Answer: ‐The new law 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 by section 1310 of the HMO Act to make a dual choice available to their employees. This meant that employees would have a choice to select one or more HMOs or select the employer's traditional insurance plan. ⫸ Early Growth and Development of Managed Care Answer: ‐Managed care significantly predates the 1973 HMO Act. ‐Employers deducted a share of the workers' salary as payment for these services as well as funding a pool for what we would now call worker compensation and disability payment funds.
⫸ Identify the various types of private health plan coverage. Answer: ‐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 ⫸ Identify the various types of government‐sponsored health coverage. Answer: ‐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) ⫸ Identify some key drivers of increasing healthcare costs Answer: ‐ 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 ⫸ Medicare Answer: ‐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 ⫸ CMS is responsible for: Answer: ‐clear policy on eligibility for CMS programs, coverage and reimbursement of healthcare services, standards for providers, and program administration. ‐Administration of comprehensive agreements with contractors and states; the performance standards that must be met in their administration, and the programmatic results that are to be achieved. ‐Monitoring the performance of contractors and states ⫸ How is Mcare financed? Answer: ‐Part A ‐ Accumulation of funds in the Part A trust fund (for Medicare Part A benefits) occurs through a 1.45% payroll tax on both employer and employee under the Social Security Act ‐Part B ‐ Accumulation of funds in the Part B trust fund occurs through the SMI Trust Fund made by Congressional authorizations and through premiums paid by enrollees. ‐Part C ‐ Not separately financed ‐Part D ‐ Financing for Part D comes from general revenues (71%), beneficiary premiums (16%), and state contributions (12%). The monthly premium paid by
⫸ Base MS‐DRG payment, hospitals receive adjusted reimbursement for the following categories of costs: Answer: ‐Cost Outliers ‐ Cost Outliers are defined as cases involving atypical lengths of stay or atypical cost ‐Transfer Policy ‐ Reduced payments for short stay patients ‐Direct/Indirect Medical Education ‐ Direct and indirect costs of patient care associated with operating approved graduate medical education program. Reimbursement is based on the ratio of interns and residents to hospital beds (IRB). ‐Disportionate Share ‐ Hospitals that serve a significant indigent population may qualify as a disproportionate share hospital and receive an additional amount determined by a formula based on the percentage of Supplemental Security Income (SSI) and Medicaid patients. Distribution of funds is based on the hospital's share of national uncompensated care for all Medicare DSH hospitals. ‐End‐Stage Renal Disease ‐ Payment is calculated using a formula that incorporates the weekly cost of dialysis (composite rate). ⫸ Medicare Reimbursement: Outpatient Prospective Payment System (OPPS) Answer: ‐The outpatient PPS published by CMS is based on Ambulatory Patient Classification (APC) groups. Under this payment method, outpatient services are assigned an APC and reimbursed on the basis of the APC classification. This payment method primarily applies to covered hospital outpatient services. ‐Like inpatient DRGs, APC rates are adjusted for geographic region and urban/rural designations, the hospitals wage index. Updates to the APC payments are published in the Federal Register. Reimbursement is received as claims are submitted and processed.
⫸ Medicare Reimbursement: Fee Schedule Reimbursement Answer: Types of fee schedules include: ‐Physicians ‐Hospital Outpatient Therapy Services ‐Hospital Diagnostic and Screening Mammography ‐Laboratories ‐Ambulance Services ⫸ Medicare Reimbursement: Value‐Based Purchasing and Quality Related Programs Answer: Medicare introduced Value‐ Based Purchasing (VBP) programs designed to financially reward or penalize providers based on their performance related to cost, quality, and patient experience measures. ⫸ Medicare Secondary Payer Questionnaire (MSPQ) Answer: ‐Medicare requires that questionnaires be completed on patients receiving both inpatient and outpatient services. ‐Frequency ‐ Hospitals must be able to demonstrate that they collected MSP information from the beneficiary or his/her representative at the time of inpatient, outpatient and recurring outpatient services, no older than 90 days, when submitting bills for their Medicare patients. ‐Questionnaire Retention ‐ Providers must keep completed MSP questionnaire copies and other MSP information for 10 years after the service date. Providers may keep hard copy files, optical images, microfilms, or microfiches. When storing the files online, keep negative and positive question responses. ⫸ Medicare Outpatient Observation Notice (MOON) Answer: ‐requires hospitals and Critical Access Hospitals (CAH) to provide notification to individuals receiving
