CSPR - Certified Specialist Payment Rep
(HFMA) Exam Questions and Answers
(Latest 2026)
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)
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
,CSPR - Certified Specialist Payment Rep
(HFMA) Exam Questions and Answers
(Latest 2026)
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
Health Plan pressure
Physician Relationships
Supply Chain
Health Maintenance Organizations (HMO) - Correct Answers
✅Referrals
,CSPR - Certified Specialist Payment Rep
(HFMA) Exam Questions and Answers
(Latest 2026)
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
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
, CSPR - Certified Specialist Payment Rep
(HFMA) Exam Questions and Answers
(Latest 2026)
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
What transition began as a result of the March 2010
healthcare reform legislation? - Correct Answers ✅A
transition toward new models of health care delivery with
corresponding changes system financing and provider
reimbursement.
Which statement is false concerning ABNs? - Correct
Answers ✅ABN began establishing new requirements for
managed care plans participating in the Medicare program.
(HFMA) Exam Questions and Answers
(Latest 2026)
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)
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
,CSPR - Certified Specialist Payment Rep
(HFMA) Exam Questions and Answers
(Latest 2026)
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
Health Plan pressure
Physician Relationships
Supply Chain
Health Maintenance Organizations (HMO) - Correct Answers
✅Referrals
,CSPR - Certified Specialist Payment Rep
(HFMA) Exam Questions and Answers
(Latest 2026)
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
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
, CSPR - Certified Specialist Payment Rep
(HFMA) Exam Questions and Answers
(Latest 2026)
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
What transition began as a result of the March 2010
healthcare reform legislation? - Correct Answers ✅A
transition toward new models of health care delivery with
corresponding changes system financing and provider
reimbursement.
Which statement is false concerning ABNs? - Correct
Answers ✅ABN began establishing new requirements for
managed care plans participating in the Medicare program.
