CSPR - Certified Specialist Payment Rep
(HFMA) NEWEST UPDATE 2025 WITH
PRACTICE QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONELS
100% GUARANTEED PASS //GRADED A+
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)
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.
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
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.
(HFMA) NEWEST UPDATE 2025 WITH
PRACTICE QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONELS
100% GUARANTEED PASS //GRADED A+
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)
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.
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
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.
