CSPR - Certified Specialist Payment
Rep (HFMA) Exam Questions +
Verified Answers 100% correct, Update
2026
Steps used to control costs of managed care include: -
correct answer ✅Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify -
correct answer ✅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 -
correct answer ✅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: -
correct answer ✅Health Maintenance Organizations (HMO)
,CSPR - Certified Specialist Payment
Rep (HFMA) Exam Questions +
Verified Answers 100% correct, Update
2026
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Identify the various types of government‐sponsored health
coverage: -
correct answer ✅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 -
correct answer ✅Demographics
Chronic Conditions
,CSPR - Certified Specialist Payment
Rep (HFMA) Exam Questions +
Verified Answers 100% correct, Update
2026
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 Organizations (HMO) -
correct answer ✅Referrals
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 four parts: -
correct answer ✅Part A - provides inpatient/hospital, hospice, and
skilled nursing coverage
, CSPR - Certified Specialist Payment
Rep (HFMA) Exam Questions +
Verified Answers 100% correct, Update
2026
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 -
correct answer ✅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.
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.
Rep (HFMA) Exam Questions +
Verified Answers 100% correct, Update
2026
Steps used to control costs of managed care include: -
correct answer ✅Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify -
correct answer ✅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 -
correct answer ✅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: -
correct answer ✅Health Maintenance Organizations (HMO)
,CSPR - Certified Specialist Payment
Rep (HFMA) Exam Questions +
Verified Answers 100% correct, Update
2026
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Identify the various types of government‐sponsored health
coverage: -
correct answer ✅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 -
correct answer ✅Demographics
Chronic Conditions
,CSPR - Certified Specialist Payment
Rep (HFMA) Exam Questions +
Verified Answers 100% correct, Update
2026
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 Organizations (HMO) -
correct answer ✅Referrals
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 four parts: -
correct answer ✅Part A - provides inpatient/hospital, hospice, and
skilled nursing coverage
, CSPR - Certified Specialist Payment
Rep (HFMA) Exam Questions +
Verified Answers 100% correct, Update
2026
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 -
correct answer ✅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.
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.
