CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) [2026]
UPDATED ACTUAL Exam | Question and Answer | A+ VERIFIED
ANSWERS
• 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
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) -✓✓ 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: -✓✓ 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 -✓✓ 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? -✓✓ 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 TRUE concerning ABNs? -✓✓ -ABNs are not required
for services that are never covered by Medicare.
UPDATED ACTUAL Exam | Question and Answer | A+ VERIFIED
ANSWERS
• 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
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) -✓✓ 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: -✓✓ 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 -✓✓ 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? -✓✓ 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 TRUE concerning ABNs? -✓✓ -ABNs are not required
for services that are never covered by Medicare.
