Certified Specialist Payment Rep (CSPR)
HFMA Review
Steps used to control costs of managed care include: - Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - Inpatient admissions for the purpose of reimbursing
hospitals for each case in a given category w/a negotiated fixed fee, regardless of
the actual costs incurred
Identify the various types of private health plan coverage - 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.
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)
Identify the various types of government‐sponsored health coverage: - 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 - Demographics