CSPR - Certified Specialist Payment
Rep (HFMA) Exam Question &
Answers 2025
Steps used to control costs of managed care include: -
CORRECT ANSWERS ✔✔Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - CORRECT ANSWERS
✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔Health Maintenance
Organizations (HMO)
,CSPR - Certified Specialist Payment
Rep (HFMA) Exam Question &
Answers 2025
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Identify the various types of government‐sponsored
health coverage: - CORRECT ANSWERS ✔✔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 ANSWERS ✔✔Demographics
Chronic Conditions
Provider payment systems - Provider payment systems
that are designed to reward volume rather than quality,
outcomes, and prevention
Consumer Perceptions
,CSPR - Certified Specialist Payment
Rep (HFMA) Exam Question &
Answers 2025
Health Plan pressure
Physician Relationships
Supply Chain
Health Maintenance Organizations (HMO) - CORRECT
ANSWERS ✔✔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
ANSWERS ✔✔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
, CSPR - Certified Specialist Payment
Rep (HFMA) Exam Question &
Answers 2025
HMO Act of 1973 - CORRECT ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔Providers will face many new
service demands and consumers will have virtually
unfettered access to those services
Rep (HFMA) Exam Question &
Answers 2025
Steps used to control costs of managed care include: -
CORRECT ANSWERS ✔✔Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - CORRECT ANSWERS
✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔Health Maintenance
Organizations (HMO)
,CSPR - Certified Specialist Payment
Rep (HFMA) Exam Question &
Answers 2025
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Identify the various types of government‐sponsored
health coverage: - CORRECT ANSWERS ✔✔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 ANSWERS ✔✔Demographics
Chronic Conditions
Provider payment systems - Provider payment systems
that are designed to reward volume rather than quality,
outcomes, and prevention
Consumer Perceptions
,CSPR - Certified Specialist Payment
Rep (HFMA) Exam Question &
Answers 2025
Health Plan pressure
Physician Relationships
Supply Chain
Health Maintenance Organizations (HMO) - CORRECT
ANSWERS ✔✔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
ANSWERS ✔✔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
, CSPR - Certified Specialist Payment
Rep (HFMA) Exam Question &
Answers 2025
HMO Act of 1973 - CORRECT ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔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 ANSWERS ✔✔Providers will face many new
service demands and consumers will have virtually
unfettered access to those services
