CSPR - Certified Specialist Payment Rep
(HFMA)2026 EXAM QUESTIONS AND VERIFIED
ANSWERS (GRADED A+) DETAILED ANSWERS|
pdf
Which of the following statements regarding employer-based health
insurance in the United States is true?
The real advent of employer-based insurance came through Blue Cross, which
was started by hospital associations during the Depression.
The Health Maintenance Organization (HMO) Act of 1973 gave qualified
HMOs the right to "mandate" an employer under certain conditions,
meaning employers:
Would have to offer HMO plans along side traditional fee-for-service medical
plans.
Which of the following is an anticipated change in the relationships
between consumers and providers?
Providers will face many new service demands and consumers will have virtually
unfettered access to those services
What transition began as a result of the March 2010 healthcare reform
legislation?
A transition toward new models of health care delivery with corresponding
changes system financing and provider reimbursement.
Which statement is false concerning ABNs?
ABN began establishing new requirements for managed care plans participating
in the Medicare program.
,Which Statement is TRUE concerning ABNs?
-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?
The pay for medical assistance for certain individuals and low-income families
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as:
Total Medical Expenses divided by Total Premiums
Provider service organizations (PSOs) function like health maintenance
organizations (HMOs) in all of the following ways, EXCEPT:
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:
-Risk pooling
-Capitalization
-Network management
Which of the following is a service provided by a well-managed third-party
administrator (TPA)?
-Administrative
-Utilization review (UR)
-Claims processing
What is tiering?
, 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?
-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?
-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:
A payment category
How is the term carve-out used when discussing managed care?
To refer to specific benefits or services
What is the term Coordination of Benefits (COB)?
A term used to describe how payment is coordinated for patients who have
coverage through two insurance policies
Which three components are used to determine the total RVU value for a
service?
-Malpractice expense
-Lowest market price for services used
-Medicare discounts
A fixed payment amount based upon the number of members assigned to
a provider, and does not vary based upon the number of services
rendered, is known as:
(HFMA)2026 EXAM QUESTIONS AND VERIFIED
ANSWERS (GRADED A+) DETAILED ANSWERS|
Which of the following statements regarding employer-based health
insurance in the United States is true?
The real advent of employer-based insurance came through Blue Cross, which
was started by hospital associations during the Depression.
The Health Maintenance Organization (HMO) Act of 1973 gave qualified
HMOs the right to "mandate" an employer under certain conditions,
meaning employers:
Would have to offer HMO plans along side traditional fee-for-service medical
plans.
Which of the following is an anticipated change in the relationships
between consumers and providers?
Providers will face many new service demands and consumers will have virtually
unfettered access to those services
What transition began as a result of the March 2010 healthcare reform
legislation?
A transition toward new models of health care delivery with corresponding
changes system financing and provider reimbursement.
Which statement is false concerning ABNs?
ABN began establishing new requirements for managed care plans participating
in the Medicare program.
,Which Statement is TRUE concerning ABNs?
-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?
The pay for medical assistance for certain individuals and low-income families
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as:
Total Medical Expenses divided by Total Premiums
Provider service organizations (PSOs) function like health maintenance
organizations (HMOs) in all of the following ways, EXCEPT:
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:
-Risk pooling
-Capitalization
-Network management
Which of the following is a service provided by a well-managed third-party
administrator (TPA)?
-Administrative
-Utilization review (UR)
-Claims processing
What is tiering?
, 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?
-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?
-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:
A payment category
How is the term carve-out used when discussing managed care?
To refer to specific benefits or services
What is the term Coordination of Benefits (COB)?
A term used to describe how payment is coordinated for patients who have
coverage through two insurance policies
Which three components are used to determine the total RVU value for a
service?
-Malpractice expense
-Lowest market price for services used
-Medicare discounts
A fixed payment amount based upon the number of members assigned to
a provider, and does not vary based upon the number of services
rendered, is known as:
