CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) ACTUAL EXA
CSPR - Certified Specialist Payment Rep (HFMA)
QUESTIONS AND ANSWERS (VERIFIED AND WELL DETAILED
Study online at https://quizlet.com/_c10bgs
ANSWERS) LATEST 2025/2026
1. Steps used to control Bundled codes
costs of managed care Capitation
include: Payer and Provider to agree on reasonable payment
2. 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
3. Identify the various HMO
types of private health Conventional
plan coverage PPO and POS
HDHP/SO plans - high-deductible health plans with a savings option;
Private - Include higher patient out-of-pocket expenditures for treat-
ments that can serve to reduce utilization/costs.
4. Managed care organi- Health Maintenance Organizations (HMO)
zations (MCO) exist pri- Preferred Provider Organizations (PPO)
marily in four forms: Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
5. Identify the various Medicare - Government; Beneficiaries enrolled in such plans, but, par-
types of governmen- ticipation in these
t‐sponsored health cov- plans is voluntary.
erage: 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)
6. Identify some key Demographics
drivers of increasing Chronic Conditions
healthcare costs Provider payment systems - Provider payment systems that are de-
signed to reward volume rather than quality, outcomes, and prevention
Consumer Perceptions
, CSPR - Certified Specialist Payment Rep (HFMA)
Study online at https://quizlet.com/_c10bgs
Health Plan pressure
Physician Relationships
Supply Chain
7. Health Maintenance Or- Referrals
ganizations (HMO) PCP
Patients must use an in-network provider for their services to be cov-
ered.
Reimbursement - majority of services offered are reimbursed through
capitation payments (PMPM)
8. Medicare is composed Part A - provides inpatient/hospital, hospice, and skilled nursing cover-
of four parts: age
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
9. HMO Act of 1973 The HMO Act of 1973 gave federally qualified HMOs the right to man-
date 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.
10. Which of the following The real advent of employer-based insurance came through Blue Cross,
statements regarding which was started by hospital associations during the Depression.
employer-based health
insurance in the United
States is true?
11. The Health Main- Would have to offer HMO plans along side traditional fee-for-service
tenance Organization medical plans.
, CSPR - Certified Specialist Payment Rep (HFMA)
Study online at https://quizlet.com/_c10bgs
(HMO) Act of 1973
gave qualified HMOs
the right to "mandate"
an employer under cer-
tain conditions, mean-
ing employers:
12. Which of the follow- Providers will face many new service demands and consumers will have
ing is an anticipated virtually unfettered access to those services
change in the rela-
tionships between con-
sumers and providers?
13. What transition began A transition toward new models of health care delivery with correspond-
as a result of the March ing changes system financing and provider reimbursement.
2010 healthcare reform
legislation?
14. Which statement is ABN began establishing new requirements for managed care plans
false concerning ABNs? participating in the Medicare program.
15. Which Statement is -ABNs are not required for services that are never covered by Medicare.
TRUE concerning ABNs? -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.
-Although ABNs can have significant financial implications for the physi-
cian, they also
serve an important fraud and abuse compliance function.
16. What is the overall func- The pay for medical assistance for certain individuals and low-income
tion of Medicaid? families
17. Total Medical Expenses divided by Total Premiums
CSPR - Certified Specialist Payment Rep (HFMA)
QUESTIONS AND ANSWERS (VERIFIED AND WELL DETAILED
Study online at https://quizlet.com/_c10bgs
ANSWERS) LATEST 2025/2026
1. Steps used to control Bundled codes
costs of managed care Capitation
include: Payer and Provider to agree on reasonable payment
2. 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
3. Identify the various HMO
types of private health Conventional
plan coverage PPO and POS
HDHP/SO plans - high-deductible health plans with a savings option;
Private - Include higher patient out-of-pocket expenditures for treat-
ments that can serve to reduce utilization/costs.
4. Managed care organi- Health Maintenance Organizations (HMO)
zations (MCO) exist pri- Preferred Provider Organizations (PPO)
marily in four forms: Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
5. Identify the various Medicare - Government; Beneficiaries enrolled in such plans, but, par-
types of governmen- ticipation in these
t‐sponsored health cov- plans is voluntary.
erage: 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)
6. Identify some key Demographics
drivers of increasing Chronic Conditions
healthcare costs Provider payment systems - Provider payment systems that are de-
signed to reward volume rather than quality, outcomes, and prevention
Consumer Perceptions
, CSPR - Certified Specialist Payment Rep (HFMA)
Study online at https://quizlet.com/_c10bgs
Health Plan pressure
Physician Relationships
Supply Chain
7. Health Maintenance Or- Referrals
ganizations (HMO) PCP
Patients must use an in-network provider for their services to be cov-
ered.
Reimbursement - majority of services offered are reimbursed through
capitation payments (PMPM)
8. Medicare is composed Part A - provides inpatient/hospital, hospice, and skilled nursing cover-
of four parts: age
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
9. HMO Act of 1973 The HMO Act of 1973 gave federally qualified HMOs the right to man-
date 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.
10. Which of the following The real advent of employer-based insurance came through Blue Cross,
statements regarding which was started by hospital associations during the Depression.
employer-based health
insurance in the United
States is true?
11. The Health Main- Would have to offer HMO plans along side traditional fee-for-service
tenance Organization medical plans.
, CSPR - Certified Specialist Payment Rep (HFMA)
Study online at https://quizlet.com/_c10bgs
(HMO) Act of 1973
gave qualified HMOs
the right to "mandate"
an employer under cer-
tain conditions, mean-
ing employers:
12. Which of the follow- Providers will face many new service demands and consumers will have
ing is an anticipated virtually unfettered access to those services
change in the rela-
tionships between con-
sumers and providers?
13. What transition began A transition toward new models of health care delivery with correspond-
as a result of the March ing changes system financing and provider reimbursement.
2010 healthcare reform
legislation?
14. Which statement is ABN began establishing new requirements for managed care plans
false concerning ABNs? participating in the Medicare program.
15. Which Statement is -ABNs are not required for services that are never covered by Medicare.
TRUE concerning ABNs? -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.
-Although ABNs can have significant financial implications for the physi-
cian, they also
serve an important fraud and abuse compliance function.
16. What is the overall func- The pay for medical assistance for certain individuals and low-income
tion of Medicaid? families
17. Total Medical Expenses divided by Total Premiums
