CSPR - Certified Specialist Payment Rep
(HFMA) Newest Update) Actual Exam Questions
with Verified Answers A+ Graded ||100%
Guaranteed A+
Steps used to control costs of managed care include:
Ans: Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
Quiz DRG is used to classify
Ans: 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
Quiz Identify the various types of private health plan coverage
Ans: 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.
Quiz Managed care organizations (MCO) exist primarily in four forms:
Ans: Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Quiz Identify the various types of government‐sponsored health coverage:
Ans: 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)
Quiz Identify some key drivers of increasing healthcare costs
Ans: 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
Quiz Health Maintenance Organizations (HMO)
Ans: 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)
Quiz Medicare is composed of four parts:
Ans: 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
Quiz HMO Act of 1973
, Ans: 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.
Quiz Which of the following statements regarding employer-based health insurance in the
United States is true?
Ans: The real advent of employer-based insurance came through Blue Cross, which was started
by hospital associations during the Depression.
Quiz The Health Maintenance Organization (HMO) Act of 1973 gave qualified HMOs the right to
"mandate" an employer under certain conditions, meaning employers:
Ans: Would have to offer HMO plans along side traditional fee-for-service medical plans.
Quiz Which of the following is an anticipated change in the relationships between consumers
and providers?
Ans: Providers will face many new service demands and consumers will have virtually
unfettered access to those services
Quiz What transition began as a result of the March 2010 healthcare reform legislation?
Ans: A transition toward new models of health care delivery with corresponding changes
system financing and provider reimbursement.
(HFMA) Newest Update) Actual Exam Questions
with Verified Answers A+ Graded ||100%
Guaranteed A+
Steps used to control costs of managed care include:
Ans: Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
Quiz DRG is used to classify
Ans: 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
Quiz Identify the various types of private health plan coverage
Ans: 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.
Quiz Managed care organizations (MCO) exist primarily in four forms:
Ans: Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Quiz Identify the various types of government‐sponsored health coverage:
Ans: 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)
Quiz Identify some key drivers of increasing healthcare costs
Ans: 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
Quiz Health Maintenance Organizations (HMO)
Ans: 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)
Quiz Medicare is composed of four parts:
Ans: 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
Quiz HMO Act of 1973
, Ans: 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.
Quiz Which of the following statements regarding employer-based health insurance in the
United States is true?
Ans: The real advent of employer-based insurance came through Blue Cross, which was started
by hospital associations during the Depression.
Quiz The Health Maintenance Organization (HMO) Act of 1973 gave qualified HMOs the right to
"mandate" an employer under certain conditions, meaning employers:
Ans: Would have to offer HMO plans along side traditional fee-for-service medical plans.
Quiz Which of the following is an anticipated change in the relationships between consumers
and providers?
Ans: Providers will face many new service demands and consumers will have virtually
unfettered access to those services
Quiz What transition began as a result of the March 2010 healthcare reform legislation?
Ans: A transition toward new models of health care delivery with corresponding changes
system financing and provider reimbursement.
