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CSPR - CERTIFIED SPECIALIST PAYMENT REP
(HFMA) 2025 UPDATED ACTUAL EXAM WITH
CORRECT SOLUTIONS.
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.
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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
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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.
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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.
CSPR - CERTIFIED SPECIALIST PAYMENT REP
(HFMA) 2025 UPDATED ACTUAL EXAM WITH
CORRECT SOLUTIONS.
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.
,2 | Page
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
,3 | Page
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.
, 4 | Page
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.
