CSPR - Certified Specialist Payment Rep
(HFMA) 2024/2025 Questions With
Complete Solutions.
Steps used to control costs of managed care include: - ✔✔Bundled codes
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 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)
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©JOSHCLAY 2025/2026. YEAR PUBLISHED 2025.
,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
2|Page
©JOSHCLAY 2025/2026. YEAR PUBLISHED 2025.
,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
3|Page
©JOSHCLAY 2025/2026. YEAR PUBLISHED 2025.
, 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
4|Page
©JOSHCLAY 2025/2026. YEAR PUBLISHED 2025.
(HFMA) 2024/2025 Questions With
Complete Solutions.
Steps used to control costs of managed care include: - ✔✔Bundled codes
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 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)
1|Page
©JOSHCLAY 2025/2026. YEAR PUBLISHED 2025.
,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
2|Page
©JOSHCLAY 2025/2026. YEAR PUBLISHED 2025.
,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
3|Page
©JOSHCLAY 2025/2026. YEAR PUBLISHED 2025.
, 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
4|Page
©JOSHCLAY 2025/2026. YEAR PUBLISHED 2025.
