CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) 2025 ACTUAL
EXAM COMPLETE 250+ QUESTIONS WITH DETAILED AND VERIFIED
ANSWERS (100% CORRECT ANSWERS) /ASSURED GRADE A+
1.The basic reimbursement methodologies used for hospital services include the following: -
answer -Percent-of-charge payments - A negotiated percentage off of billed charges
and can be applied to any or all of the services that the hospital provides.
-Per diem payments - Refers to a fixed amount per patient per inpatient day.
-Case rate payments - Represent a fixed price for specified care by paying an agreed-upon rate
for a specific healthcare service.
-Carve-outs - Sometimes refer to specific benefits or services that are administered separately
from the rest of the managed care plan and that may be managed by other third parties.
2.Professional services reimbursement methodologies include the following: - answer -
Discountsbasednegotiatedfeeschedules
-Payment based on Resource Based Relative Value System (RBRVS)
-Capitation
-Case rates
3.The four value-based payment models include the following - answer -Bundled payment
-RiskSharing
-Patient-Centered Medical Home/Guided Care
-Pay for Performance
4.Healthcare financial leaders should focus on initiatives that will help them increase their
organization's revenue/profit/ margins, such as: - answer -Payment policing and standardization
of contract requirements.
-Contract performance modeling.
,-Shift in volume and cost risk to hospitals.
-Health plan consolidation.
5.The trends which have arisen from the focus on reducing healthcare costs while improving
quality and outcomes include the following: - answer -Shift from broad-based toward more
focused efforts
-Reduction of administrative costs
-Greater physician involvement
-Greater patient engagement
-Focus of case management on care and resources
-Increased use of team-based health care
6.The three technique application methods used for utilization management include the
following: - answer -Prospective UM Techniques - UM reviews the need for inpatient care or
other care before admission. The health plan
determines, at this point, whether it will pay for the service
-Concurrent UM Techniques - Authorization required during a patient's inpatient admission
-Retrospective UM Techniques - Authorization reviews to determine medical necessity of a
service, treatment or
procedure
7.Catastrophic Case Management - answer used to manage diseases associated with very high
costs of care.
8.PCMH model - answer a term used to describe a model of care in which primary care services
are delivered to families in an accessible, continuous, comprehensive, and integrated fashion.
, 9.The specific roles and responsibility of each level within the small physician practice managed
care infrastructure included the following: - answer -Practice Manager - Oversee all operational
aspects of the practice, including managed care contracting.
-Physician Leader(s) - Provide input to the practice manager regarding expected/target
reimbursement rates and help identify any specific aspects of the contract that may be difficult
to administer.
-Registration Staff - Assist with eligibility verification and accurate entry of patient insurance
information into the practice management or billing system.
-Clinical Staff - Must be familiar with payer requirements for appropriate documentation of
medical necessity and protocols for pre-authorizations.
-Billing Staff - Responsible for submitting claims to the appropriate payers and managing
payments received from payers and patients.
10.Electronic Data Interchange (EDI) - answer the exchange of computerized data in a
standardized format allows both healthcare providers and payers to exchange common
information required to improve the quality of care while measurably reducing the cost of that
care.
11.Information required for claims processing includes the following: - answer -Patient and/or
enrollee identification, DOB, and sex
-Assigned group
-Provider or referring provider identification, as appropriate
-Dateofservice
-Type of service
-Type of diagnosis/major diagnostic category -Procedure code(s): CPT and HCPCS codes
-COB information
▪ Primary, secondary, and other diagnosis codes as necessary (as many as five may be needed
under DRGs for hospital reimbursement), including
-DRG classification
-Episode of care identifier
EXAM COMPLETE 250+ QUESTIONS WITH DETAILED AND VERIFIED
ANSWERS (100% CORRECT ANSWERS) /ASSURED GRADE A+
1.The basic reimbursement methodologies used for hospital services include the following: -
answer -Percent-of-charge payments - A negotiated percentage off of billed charges
and can be applied to any or all of the services that the hospital provides.
-Per diem payments - Refers to a fixed amount per patient per inpatient day.
-Case rate payments - Represent a fixed price for specified care by paying an agreed-upon rate
for a specific healthcare service.
-Carve-outs - Sometimes refer to specific benefits or services that are administered separately
from the rest of the managed care plan and that may be managed by other third parties.
2.Professional services reimbursement methodologies include the following: - answer -
Discountsbasednegotiatedfeeschedules
-Payment based on Resource Based Relative Value System (RBRVS)
-Capitation
-Case rates
3.The four value-based payment models include the following - answer -Bundled payment
-RiskSharing
-Patient-Centered Medical Home/Guided Care
-Pay for Performance
4.Healthcare financial leaders should focus on initiatives that will help them increase their
organization's revenue/profit/ margins, such as: - answer -Payment policing and standardization
of contract requirements.
-Contract performance modeling.
,-Shift in volume and cost risk to hospitals.
-Health plan consolidation.
5.The trends which have arisen from the focus on reducing healthcare costs while improving
quality and outcomes include the following: - answer -Shift from broad-based toward more
focused efforts
-Reduction of administrative costs
-Greater physician involvement
-Greater patient engagement
-Focus of case management on care and resources
-Increased use of team-based health care
6.The three technique application methods used for utilization management include the
following: - answer -Prospective UM Techniques - UM reviews the need for inpatient care or
other care before admission. The health plan
determines, at this point, whether it will pay for the service
-Concurrent UM Techniques - Authorization required during a patient's inpatient admission
-Retrospective UM Techniques - Authorization reviews to determine medical necessity of a
service, treatment or
procedure
7.Catastrophic Case Management - answer used to manage diseases associated with very high
costs of care.
8.PCMH model - answer a term used to describe a model of care in which primary care services
are delivered to families in an accessible, continuous, comprehensive, and integrated fashion.
, 9.The specific roles and responsibility of each level within the small physician practice managed
care infrastructure included the following: - answer -Practice Manager - Oversee all operational
aspects of the practice, including managed care contracting.
-Physician Leader(s) - Provide input to the practice manager regarding expected/target
reimbursement rates and help identify any specific aspects of the contract that may be difficult
to administer.
-Registration Staff - Assist with eligibility verification and accurate entry of patient insurance
information into the practice management or billing system.
-Clinical Staff - Must be familiar with payer requirements for appropriate documentation of
medical necessity and protocols for pre-authorizations.
-Billing Staff - Responsible for submitting claims to the appropriate payers and managing
payments received from payers and patients.
10.Electronic Data Interchange (EDI) - answer the exchange of computerized data in a
standardized format allows both healthcare providers and payers to exchange common
information required to improve the quality of care while measurably reducing the cost of that
care.
11.Information required for claims processing includes the following: - answer -Patient and/or
enrollee identification, DOB, and sex
-Assigned group
-Provider or referring provider identification, as appropriate
-Dateofservice
-Type of service
-Type of diagnosis/major diagnostic category -Procedure code(s): CPT and HCPCS codes
-COB information
▪ Primary, secondary, and other diagnosis codes as necessary (as many as five may be needed
under DRGs for hospital reimbursement), including
-DRG classification
-Episode of care identifier
