CSPR - Certified Specialist Payment Rep
(HFMA) 2026 Questions With Complete
Solutions.
Steps used to control costs of Bundled codes
managed care include: 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 HMO
private health plan Conventional
coverage PPO and POS
HDHP/SO plans - high-deductible health plans with a savings
option; Private - Include higher patient outof-pocket
expenditures for treatments that can serve to reduce
utilization/costs.
Managed care organizations Health Maintenance Organizations (HMO)
(MCO) exist primarily in four Preferred Provider Organizations (PPO)
forms:
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
, Medicare - Government; Beneficiaries enrolled in such
plans, but, participation in these plans is voluntary.
Identify the various types of Medicaid
government‐sponsored Medicaid Managed Care - Medicaid beneficiaries are required to
health coverage: select and enroll in a managed care plan.
Medicare Managed Care (a.k.a. Medicare Advantage
Plans)
Identify some key drivers of Demographics
increasing healthcare costs 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
Health Maintenance Referrals
Organizations (HMO) PCP
Patients must use an in-network provider for their services to be
covered.
Reimbursement - majority of services offered are reimbursed
through capitation payments (PMPM)
Medicare is composed of Part A - provides inpatient/hospital, hospice, and skilled
four parts: 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
, HMO Act of 1973 The HMO Act of 1973 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 to
make a dual choice available to their employees.
The real advent of employer-based insurance came
Which of the following through Blue Cross, which was started by hospital
statements regarding associations during the Depression.
employer-based health
insurance in the United
States is true?
The Health Maintenance Would have to offer HMO plans along side traditional fee-for-service
Organization (HMO) Act of medical plans.
1973 gave qualified HMOs
the right to "mandate" an
employer under certain
conditions, meaning
employers:
Which of the following is an Providers will face many new service demands and
anticipated change in the consumers will have virtually unfettered access to those
relationships between services
consumers and providers?
What transition began as a A transition toward new models of health care delivery with
result of the March 2010 corresponding changes system financing and provider
healthcare reform reimbursement.
legislation?
Which statement is false ABN began establishing new requirements for managed care
concerning ABNs? plans participating in the Medicare program.
(HFMA) 2026 Questions With Complete
Solutions.
Steps used to control costs of Bundled codes
managed care include: 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 HMO
private health plan Conventional
coverage PPO and POS
HDHP/SO plans - high-deductible health plans with a savings
option; Private - Include higher patient outof-pocket
expenditures for treatments that can serve to reduce
utilization/costs.
Managed care organizations Health Maintenance Organizations (HMO)
(MCO) exist primarily in four Preferred Provider Organizations (PPO)
forms:
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
, Medicare - Government; Beneficiaries enrolled in such
plans, but, participation in these plans is voluntary.
Identify the various types of Medicaid
government‐sponsored Medicaid Managed Care - Medicaid beneficiaries are required to
health coverage: select and enroll in a managed care plan.
Medicare Managed Care (a.k.a. Medicare Advantage
Plans)
Identify some key drivers of Demographics
increasing healthcare costs 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
Health Maintenance Referrals
Organizations (HMO) PCP
Patients must use an in-network provider for their services to be
covered.
Reimbursement - majority of services offered are reimbursed
through capitation payments (PMPM)
Medicare is composed of Part A - provides inpatient/hospital, hospice, and skilled
four parts: 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
, HMO Act of 1973 The HMO Act of 1973 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 to
make a dual choice available to their employees.
The real advent of employer-based insurance came
Which of the following through Blue Cross, which was started by hospital
statements regarding associations during the Depression.
employer-based health
insurance in the United
States is true?
The Health Maintenance Would have to offer HMO plans along side traditional fee-for-service
Organization (HMO) Act of medical plans.
1973 gave qualified HMOs
the right to "mandate" an
employer under certain
conditions, meaning
employers:
Which of the following is an Providers will face many new service demands and
anticipated change in the consumers will have virtually unfettered access to those
relationships between services
consumers and providers?
What transition began as a A transition toward new models of health care delivery with
result of the March 2010 corresponding changes system financing and provider
healthcare reform reimbursement.
legislation?
Which statement is false ABN began establishing new requirements for managed care
concerning ABNs? plans participating in the Medicare program.
