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HFMA CSPR EXAM CERTIFIED SPECIALIST PAYMENT REP
EXAM | ALL QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) | LATEST EXAM | JUST RELEASED |
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Medical loss ratio (MLR) is a synonymous term for: A) Medical cost revenue (MCR) B) Medical cost ratio (MCR) C) Medical coverage revenue (MCR) D) Medicaid cost ratio (MCR) ---------CORRECT ANSWER-----------------B) Medical cost ratio (MCR) Key differences to consider between inpatient and outpatient services when contracting include all of the following EXCEPT: A) Site of service differentials B) Payment methodologies C) Patient experience and satisfaction D) Operational policies and processes ---------CORRECT ANSWER---------- -------C) Patient experience and satisfaction Which of the following is not an example of an objective criteria set that may be applied in utilization management? A) InterQual B) HEDIS C) Milliman D) NCQA ---------CORRECT ANSWER-----------------C) Milliman Which of the following is a trend in payment for healthcare services?
A) Bundled payment B) Cost-based payments C) Care coordination D) Capitation ---------CORRECT ANSWER-----------------A) Bundled payment Integrated healthcare delivery systems are most capable of successfully managing which type of payer agreement? A) Monthly management fee B) Specialist fee for service C) Hospital fee for service D) Global capitation ---------CORRECT ANSWER-----------------D) Global capitation A clean claim is: A) A properly completed billing form, ICD-10 or CPT- 4 B) A properly completed billing form, UB-04 or CMS 1500 C) A properly completed billing form, CMS 1500 D) A properly completed billing form, ICD-10 or CMS 1500 --------- CORRECT ANSWER-----------------B) A properly completed billing form, UB- 04 or CMS 1500 To ensure that patients have the education, tools, and support they need to make decisions and participate in their own care is the goal of: A) The Patient Protection and Affordable Care Act (PPACA) B) A patient-centered medical home (PCMH) C) Accountable care organizations (ACO's) D) Managed care organizations (MCO's) ---------CORRECT ANSWER------- ----------B) A patient-centered medical home (PCMH)
D) MS-DRG payment ---------CORRECT ANSWER-----------------C) Medicare payments to physicians Which option is NOT a practice used to control the costs of managed care? A) Delivering services that are reasonable, and payers agree on medical necessity and reimburse for services B) Combining services, bundling associated charges, determining an appropriate charge the that set of services C) Making advance payment to providers for all services needed to care for a member D) The payer and provider agreeing on a reasonable payment for each service ---------CORRECT ANSWER-----------------C) Making advance payment to providers for all services needed to care for a member Under Title XIX of the Social Security Act, Medicaid: A) Mandates medical services for certain individuals and low-income families B) Advocates medical assistance for certain individuals and low-come families C) Pays for medical assistance for certain individuals and low-income families D) Provides medical referrals for certain individuals and low-income families ---------CORRECT ANSWER-----------------C) Pays for medical assistance for certain individuals and low-income families Choice of providers and plans, which is a patient protection for managed Medicare enrollees, involes:
A) Requiring physicians to disclose to Medicare any financial arrangements that create incentives limiting care B) Requiring emergency services to be covered when and where the need arises C) Requiring plans to provide critical information to consumers, both annually and upon request D) Requiring that medically necessary services be available to beneficiaries 24 hours a day, 7 days a week ---------CORRECT ANSWER-----------------C) Requiring plans to provide critical information to consumers, both annually and upon request The CMS hopital Value-Based Purchasing (VBP) program links a percentage of a hospital's payment to performance on quality measures. A component of the hospital's VBP total performance score is: A) Patient Experience B) Access to care C) Case mix indexes D) Net margin per case ---------CORRECT ANSWER-----------------A) Patient Experience All of the following are true regarding a non-direct PPO, EXCEPT: A) Many providers sign such agreements, without understanding that there is little volume promised in exchange for any preferred rates B) Many providers sign such agreements, without understanding that there is no specific steerage to contracted providers C) The arrangements does not discount provider fees with no incentives for patients to access the provider's services
The Emergency Treatment and Active Labor Act (EMTALA) governs when a patient may be transferred from one hospital to another when in a(n) condition: A) Life threatening B) Non-emergency C) Stable D) Chronic ---------CORRECT ANSWER-----------------A) Life threatening STAR ratings are used to indicate the quality of: A) Accountable Care Organizations performance B) Medicare Advantage health plan performance C) Services provided by hospitals D) Services provided by physicians ---------CORRECT ANSWER-------------- ---B) Medicare Advantage health plan performance To evaluate an organization's compliance with the CMS COP standards and other accreditation requirements, is the purpose of: A) A comprehensive accreditation process B) Recovery Audits C) The American Osteopathic Association D) A clean claim ---------CORRECT ANSWER-----------------A) A comprehensive accreditation process What is tiering? A) Typically fixed dollar amounts paid by the insured directly to the practitioner per episode of care B) Healthcare coverage products featuring narrow networks, high cost sharing and very low premiums
C) An effort by insurers to increase premiums and to address calls from employers and the public for improved quality D) The ranking or classifying of one or more of the provider delivery system components to influence choice ---------CORRECT ANSWER----------------- D) The ranking or classifying of one or more of the provider delivery system components to influence choice Which piece of information is NOT necessary for claims processing? A) Provider or referring provider identification B) Family medical history C) Type of service D) Procedure code ---------CORRECT ANSWER-----------------B) Family medical history Which option is NOT true concerning the Consolidated Omnibus Budget Reconciliation ACT (COBRA)? A) COBRA beneficiaries generally are eligible for group coverage during a maximum of 48 months for qualifying events B) COBRA coverage begins on the date that healthcare coverage would otherwise have been lost because of a qualifying event C) COBRA establishes specific criteria for plans, qualified beneficiaries, and qualifying events to be eligible for benefits D) Group health coverage for COBRA participants is usually more expensive than health coverage for active employee ---------CORRECT ANSWER-----------------A) COBRA beneficiaries generally are eligible for group coverage during a maximum of 48 months for qualifying events
B) By using a formula that compares the states average per capita income level with the national income average C) By ranking states according to the percentage of residents at the poverty level D) By averaging the percentage paid in the five previous years --------- CORRECT ANSWER-----------------B) By using a formula that compares the states average per capita income level with the national income average The different rates charged on the basis of the number and relationships of the people covered under one employee's plan is known as: A) Ratings B) Rating tiers C) Structures D) Tier structures ---------CORRECT ANSWER-----------------B) Rating tiers A Patient Centered Medical Home has all the following characteristics except: A) Comprehensive and continuous care B) Health information technology C) Limited access to care D) Team-based care delivery ---------CORRECT ANSWER-----------------C) Limited access to care All are areas that a NCQA review covers, EXCEPT: A) Medical records review & Member rights and responsibilities B) Credentialing review & Preventive and adaptive health services C) QA review & UM review D) Physician rights and responsibilities & Certification review --------- CORRECT ANSWER-----------------D) Physician rights and responsibilities & Certification review
They are available to everyone, not just employees of a small business or the self-employed. This is a benefit of: A) NCQA B) CDHP C) Medicare D) HSA ---------CORRECT ANSWER-----------------C) Medicare Coordination of Benefits is essential to: A) Identifying the correct primary/secondary insure for proper payment B) Determining charity care C) Identifying the patient copay at the time of service D) Ensuring appropriate care is provided ---------CORRECT ANSWER------- ----------A) Identifying the correct primary/secondary insure for proper payment Patient and/or enrollee identification, age, gender, date of service, and diagnosis codes are all regarded as: A) Information not necessary for claims processing B) Required information for health plans reporting C) Information used to establish expected reimbursement D) Information required for claims processing ---------CORRECT ANSWER- ----------------D) Information required for claims processing When modeling the proposed payer's contractual reimbursement, you should include: A) All claim data B) All Medicare claim data C) All commercial claim data
---------A) Is part of the Medicare policy that provides outpatient prescription drug coverage With regards to managed care, a hospital's board of directors is responsible for: A) Understanding the hospital's contracting strategy B) Reviewing all managed care contracting arrangements C) Ensuring appropriate IT is in a place to process claims D) Safeguarding that the hospital pricing isn't available to consumers --------
- CORRECT ANSWER-----------------B) Reviewing all managed care contracting arrangements Deductibles, copayments, coinsurance, and out of pocket maximums are all financial mechanisms of a benefit plan designed to: A) Alleviate provider "revenue stress" B) Subsidize costs C) Share costs D) Contain costs ---------CORRECT ANSWER-----------------C) Share costs High-Deductible health plans are: A) Private healthcare coverage which includes higher patient out-of-pocket expenditures for treatments B) Government healthcare coverage where beneficiaries are required to select and enroll in a managed care plan C) Government health care where beneficiaries enroll in such plans but participation in these plans is voluntary D) Private healthcare coverage that includes additional products such as PPO and POS, with typically higher cost sharing ---------CORRECT
ANSWER-----------------A) Private healthcare coverage which includes higher patient out-of-pocket expenditures for treatments All are key objectives of the Patient Protection and Affordable Care Act, EXCEPT: A) Eliminate overpayment in Medicare Advantage programs B) Extend health insurance coverage & Reduce the deficit C) Address insurance company abuses & Make health insurance more effective D) Verify information such as malpractice history, and other basic physician credentials ---------CORRECT ANSWER-----------------D) Verify information such as malpractice history, and other basic physician credentials Advocates of price transparency argue that disclosing the costs of healthcare will: A) Lower consumer health costs by increasing competition among providers B) Confuse patients and disincentivize them to seek healthcare C) Prevent hospitals from seeking reimbursement to cover cost of care D) Conflict with the spirit of privately negotiated contract rates --------- CORRECT ANSWER-----------------A) Lower consumer health costs by increasing competition among providers Direct Contracting is defined as: A) A payer arrangement that results from an MCO that sells or rents its PPO provider network to an insurance broker B) A single-employer or multi-employer healthcare alliance that contracts directly with providers for healthcare services
D) The least intensive setting required to provide the care appropriately ----- ----CORRECT ANSWER-----------------D) The least intensive setting required to provide the care appropriately Detailed contract performance assessments; negotiating-strategy planning briefs; and financial and volume analysis models are all: A) Tools used to optimize contract performance B) Key components of a typical contract audit C) Performance evaluation tools D) Contract evaluation criteria ---------CORRECT ANSWER-----------------A) Tools used to optimize contract performance The medical cost ratio is equal to the: A) Total medical expenses divided by total premiums B) Total Medicare payments divided by the total premiums C) Total resource allocation costs divided by total premiums D) Total medical expenses divided by total revenue ---------CORRECT ANSWER-----------------A) Total medical expenses divided by total premiums The payment methodologies that could be used with Accountable Care Organizations (ACO's) EXCEPT: A) Fee-for-service payments B) Risk sharing arrangements C) Global payments D) DRG's and APCs ---------CORRECT ANSWER-----------------A) Fee-for- service payments
CDHPs provide some benefits not found in a typical HMO or PPO. All are CDHP benefits, EXCEPT: A) Allowing consumers to purchase coverage for things not typically covered B) Consumers being required to track their own claims and payments C) Representing an additional benefit plan choice tht adds to the common dual-choice employer offerings D) Fewer barriers to physician access ---------CORRECT ANSWER----------- ------D) Fewer barriers to physician access The legislation that governs health benefit plans of self-insured, self-funded employers in the United States is known as: A) The Employee Retirement Income Security Act of 1974 (ERISA) B) Det Norske Veritas C) The 1986 Consolidated Omnibus Budget Reconcilliation Act (COBRA) D) The Health Maintenance Organization Act of 1973 ---------CORRECT ANSWER-----------------A) The Employee Retirement Income Security Act of 1974 (ERISA) To promote healthcare quality through accreditation and certification programs, is the purpose of: A) URAC B) ERISA C) COBRA D) EMTALA ---------CORRECT ANSWER-----------------A) URAC Hospitals, health systems, and large physician groups are likely to have robust governance models models with supporting organizational
ANSWER-----------------D) Referring to specific benefits or services that are administered separately from the rest of the managed care plan The Patient Centered Medical Home model is expected to reduce costs by: A) All of the above B) Reducing emrgency room visits C) Reducing inpatient admissions D) Increasing preventive care ---------CORRECT ANSWER-----------------A) All of the above The purpose of the Medicare Value-Based Purchasing (VBP) program is: A) To provide better services and a broader range of options for Medicare beneficiaries in health plans B) To financially reward or penalize physicians based on their performance related to cost, quality, and patient experience measures C) To provide "targeted, accessible, continuous, and coordinated care to Medicare beneficiaries..." D) To provide differential payments to physicians based on the quality of care provided to Medicare beneficiaries ---------CORRECT ANSWER--------- --------D) To provide differential payments to physicians based on the quality of care provided to Medicare beneficiaries The following are quality-related outcomes that can be measured except: A) Transplant quality indicators B) Risk-adjusted mortality rates
C) Level of physician compnesation D) Readmission rates ---------CORRECT ANSWER-----------------C) Level of physician compnesation Which fixed-rate payment method uses a single price for an inpatient stay, outpatient procedure, or outpatient diagnosis? A) Indexed case rate B) Global case rate C) Indexed per diem D) Front-loaded per diem ---------CORRECT ANSWER-----------------B) Global case rate Medicaid is: A) Government health coverage where beneficiaries are required to select and enroll in a managed care plan B) Private healthcare coverage which includes higher patient out-of-pocket expenditures for treatments C) Private healthcare coverage that includes additional products such as PPO and POS, with typically higher cost sharing D) Government health care where beneficiaries enroll in such plans but participation in these plans is voluntary ---------CORRECT ANSWER---------- -------D) Government health care where beneficiaries enroll in such plans but participation in these plans is voluntary Which option is NOT true regarding prospective UM techniques? A) It requires an opinion from a practitioner other than the specialist making the recommendation to confirm that a proposed treatment is appropriate
