CSPR - Certified Specialist Payment Rep
(HFMA) Exam Study Guide |
Comprehensive Review & Practice
Questions | 2026/2027
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)
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
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
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.
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.
, 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
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.
Which statement is false concerning ABNs? - correct answer-ABN began
establishing new requirements for managed care plans participating in the
Medicare program.
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.
What is the overall function of Medicaid? - correct answer-The pay for medical
assistance for certain individuals and low-income families
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - correct
answer-Total Medical Expenses divided by Total Premiums
(HFMA) Exam Study Guide |
Comprehensive Review & Practice
Questions | 2026/2027
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)
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
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
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.
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.
, 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
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.
Which statement is false concerning ABNs? - correct answer-ABN began
establishing new requirements for managed care plans participating in the
Medicare program.
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.
What is the overall function of Medicaid? - correct answer-The pay for medical
assistance for certain individuals and low-income families
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - correct
answer-Total Medical Expenses divided by Total Premiums
