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CSPR - CERTIFIED SPECIALIST
PAYMENT REP (HFMA) Q UESTIONS
WITH CORRECT ANSWERS
Question : Which of the following statements regarding
employer-based health insurance in the United States is true?
Correct answer: The real advent of employer-based insurance
came through Blue Cross, which was started by hospital associations during the Depression.
Question : The Health Maintenance Organization (HMO) Act
of 1973 gave qualified HMOs the right to "mandate" an
employer under certain conditions, meaning employers:
Correct answer: Would have to offer HMO plans along side
traditional fee-for-service medical plans.
Question : Which of the following is an anticipated change in
the relationships between consumers and providers?
Correct answer: Providers will face many new service
demands and consumers will have virtually unfettered access to those services
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Question : What transition began as a result of the March
2010 healthcare reform legislation?
Correct answer: A transition toward new models of health
care delivery with corresponding changes system financing and provider reimbursement.
Question : Which statement is false concerning ABNs?
Correct answer: ABN began establishing new requirements
for managed care plans participating in the Medicare program.
Question : Which Statement is TRUE concerning ABNs?
Correct 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.
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Question : Provider service organizations (PSOs) function like
health maintenance organizations (HMOs) in all of the
following ways, EXCEPT:
Correct answer: Ties to the healthcare delivery industry rather
than the insurance industry
Question : Provider service organizations (PSOs) function like
health maintenance organizations (HMOs) in all of the
following ways:
Correct answer: Risk pooling
Capitalization Network management
Question : Which of the following is a service provided by a
well-managed third-party administrator (TPA)?
Correct answer: Administrative
Utilization review (UR) Claims processing
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Question : Which option is a practice used to control costs of
managed care?
Correct 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.
Question : Which option is a risk involved in per diem
payments?
Correct 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
Question : Which three components are used to determine the
total RVU value for a service?
Correct answer: Malpractice expense
Lowest market price for services used