HFMA CSPR EXAM AND STUDYGUIDE NEWEST 2026 ACTUAL EXAM COMPLETE
200 QUESTIONS AND CORRECT DETAILED ANSWERS/NEWEST UPDATE!!!
Question 1
Which of the following is considered a standard step used by managed care organizations to
control healthcare costs?
A) Increasing the number of out-of-network benefits
B) Transitioning from capitation to pure fee-for-service
C) Utilizing bundled codes to combine associated charges
D) Eliminating utilization review processes
E) Allowing providers to set independent market rates without payer agreement
Correct Answer: C) Utilizing bundled codes to combine associated charges
Rationale: Managed care organizations use bundled codes, capitation, and negotiated
reasonable payment agreements between payers and providers to maintain cost-efficiency
and reduce fragmented billing.
Question 2
What is the primary function of a Diagnosis-Related Group (DRG) in the hospital setting?
A) To determine the professional fee for physician services in the clinic
B) To classify inpatient admissions for the purpose of fixed-fee reimbursement
C) To manage outpatient prescription drug formularies
D) To track patient satisfaction scores across various departments
E) To calculate the malpractice insurance premiums for surgeons
Correct Answer: B) To classify inpatient admissions for the purpose of fixed-fee
reimbursement
Rationale: A DRG is used to pay hospitals a negotiated fixed fee for each case in a given
category, regardless of the actual costs incurred by the hospital during that specific stay.
Question 3
Private health plan coverage in the United States includes which of the following categories?
A) Medicare Part A and Medicaid only
B) HMO, Conventional, PPO, POS, and HDHP/SO plans
C) TRICARE and Indian Health Services
D) Social Security Disability Insurance only
E) Federal Employee Retirement System healthcare
Correct Answer: B) HMO, Conventional, PPO, POS, and HDHP/SO plans
Rationale: Private coverage spans a variety of models including Health Maintenance
Organizations, Preferred Provider Organizations, Point of Service plans, and High-
Deductible Health Plans with a savings option.
Question 4
Managed care organizations (MCOs) primarily exist in which of the following four forms?
A) HMO, PPO, POS, and EPO
, 2
B) DRG, RVU, MLR, and CPT
C) Medicare, Medicaid, COBRA, and ERISA
D) TPA, ASO, PSO, and IDS
E) HMO, PSO, ACO, and SNF
Correct Answer: A) HMO, PPO, POS, and EPO
Rationale: MCOs are structured as Health Maintenance Organizations, Preferred Provider
Organizations, Point of Service organizations, and Exclusive Provider Organizations.
Question 5
Which of the following describes a government-sponsored health coverage plan?
A) Exclusive Provider Organization (EPO)
B) High-Deductible Health Plan (HDHP)
C) Medicare Managed Care (Medicare Advantage)
D) Fully insured employer-based PPO
E) Self-funded ERISA plan
Correct Answer: C) Medicare Managed Care (Medicare Advantage)
Rationale: Government-sponsored plans include Medicare (Parts A-D), Medicaid, and the
managed care versions of both, such as Medicare Advantage.
Question 6
What is identified as a key driver of increasing healthcare costs in the United States?
A) Decreasing life expectancy among the general population
B) Provider payment systems that reward volume over quality and outcomes
C) A shift toward perfectly healthy lifestyle choices by all consumers
D) Increased transparency in hospital supply chain pricing
E) Reductions in health plan administrative fees
Correct Answer: B) Provider payment systems that reward volume over quality and
outcomes
Rationale: Cost drivers include demographics, chronic conditions, provider payment
systems focused on volume, consumer perceptions, and supply chain expenses.
Question 7
In a Health Maintenance Organization (HMO), what is a requirement for a patient to have their
services covered?
A) They must seek care from any provider in the state
B) They must use an in-network provider and typically require a PCP referral
C) They must pay a separate deductible for every specialist visit
D) They must be enrolled in Medicare Part A
E) They must be employed by a company with fewer than 25 employees
Correct Answer: B) They must use an in-network provider and typically require a PCP
referral
, 3
Rationale: HMOs are characterized by the use of a Primary Care Physician (PCP), the
requirement for referrals to see specialists, and the mandate to use in-network providers
for coverage.
Question 8
Medicare Part A provides coverage for which type of service?
A) Outpatient physician office visits
B) Prescription drugs through private pharmacies
C) Inpatient hospital, hospice, and skilled nursing coverage
D) Long-term custodial nursing home care
E) Routine dental and vision examinations
Correct Answer: C) Inpatient hospital, hospice, and skilled nursing coverage
Rationale: Medicare Part A is specifically dedicated to inpatient/hospital care, skilled
nursing facilities, and hospice services.
Question 9
Medicare Part B is designed to cover which of the following?
A) Inpatient surgical stays
B) Home health care exclusively
C) Outpatient and medical coverage
D) Medicare Advantage supplemental benefits
E) Prescription drug manufacturing costs
Correct Answer: C) Outpatient and medical coverage
Rationale: Medicare Part B provides coverage for medically necessary services like doctors'
services and outpatient care.
Question 10
Medicare Advantage plans are also known as:
A) Medicare Part A
B) Medicare Part B
C) Medicare Part C
D) Medicare Part D
E) Medigap
Correct Answer: C) Medicare Part C
Rationale: Medicare Part C is an alternative way to receive Medicare benefits through
private managed care plans known as Medicare Advantage.
Question 11
Which part of Medicare provides prescription drug coverage?
A) Part A
B) Part B
, 4
C) Part C
D) Part D
E) Part E
Correct Answer: D) Part D
Rationale: Medicare Part D was established to provide prescription drug benefits to
Medicare beneficiaries.
Question 12
The HMO Act of 1973 required for-profit companies with 25 or more employees to:
A) Eliminate all private insurance options
B) Provide free healthcare to all dependents of employees
C) Offer a "dual choice" by making HMO plans available alongside traditional plans
D) Pay a fine if they did not utilize capitated payment models
E) Directly contract with the federal government for healthcare
Correct Answer: C) Offer a "dual choice" by making HMO plans available alongside
traditional plans
Rationale: The 1973 Act mandated that certain employers offer federally qualified HMOs as
an option to their employees, fostering the growth of managed care.
Question 13
Which statement is TRUE regarding Advance Beneficiary Notices (ABNs)?
A) They are required for every service a patient receives, regardless of coverage.
B) They notify the patient that a specific service may not be covered by Medicare.
C) They are only used in Medicaid managed care plans.
D) They guarantee that Medicare will pay for the service if signed.
E) They are used to bill the patient for services that are never covered by Medicare.
Correct Answer: B) They notify the patient that a specific service may not be covered by
Medicare.
Rationale: An ABN notifies the patient before receiving a service that Medicare may not
cover it, allowing the patient to decide whether to proceed and pay out of pocket.
Question 14
How is the Medical Loss Ratio (MLR) calculated?
A) Total Premiums divided by Total Medical Expenses
B) Total Medical Expenses divided by Total Premiums
C) Administrative Costs divided by Net Income
D) Total Claims minus Total Deductibles
E) Inpatient Costs divided by Outpatient Revenue
Correct Answer: B) Total Medical Expenses divided by Total Premiums
Rationale: The MLR represents the percentage of premium dollars an insurer spends on
medical claims and quality improvement versus administrative costs.
200 QUESTIONS AND CORRECT DETAILED ANSWERS/NEWEST UPDATE!!!
Question 1
Which of the following is considered a standard step used by managed care organizations to
control healthcare costs?
A) Increasing the number of out-of-network benefits
B) Transitioning from capitation to pure fee-for-service
C) Utilizing bundled codes to combine associated charges
D) Eliminating utilization review processes
E) Allowing providers to set independent market rates without payer agreement
Correct Answer: C) Utilizing bundled codes to combine associated charges
Rationale: Managed care organizations use bundled codes, capitation, and negotiated
reasonable payment agreements between payers and providers to maintain cost-efficiency
and reduce fragmented billing.
Question 2
What is the primary function of a Diagnosis-Related Group (DRG) in the hospital setting?
A) To determine the professional fee for physician services in the clinic
B) To classify inpatient admissions for the purpose of fixed-fee reimbursement
C) To manage outpatient prescription drug formularies
D) To track patient satisfaction scores across various departments
E) To calculate the malpractice insurance premiums for surgeons
Correct Answer: B) To classify inpatient admissions for the purpose of fixed-fee
reimbursement
Rationale: A DRG is used to pay hospitals a negotiated fixed fee for each case in a given
category, regardless of the actual costs incurred by the hospital during that specific stay.
Question 3
Private health plan coverage in the United States includes which of the following categories?
A) Medicare Part A and Medicaid only
B) HMO, Conventional, PPO, POS, and HDHP/SO plans
C) TRICARE and Indian Health Services
D) Social Security Disability Insurance only
E) Federal Employee Retirement System healthcare
Correct Answer: B) HMO, Conventional, PPO, POS, and HDHP/SO plans
Rationale: Private coverage spans a variety of models including Health Maintenance
Organizations, Preferred Provider Organizations, Point of Service plans, and High-
Deductible Health Plans with a savings option.
Question 4
Managed care organizations (MCOs) primarily exist in which of the following four forms?
A) HMO, PPO, POS, and EPO
, 2
B) DRG, RVU, MLR, and CPT
C) Medicare, Medicaid, COBRA, and ERISA
D) TPA, ASO, PSO, and IDS
E) HMO, PSO, ACO, and SNF
Correct Answer: A) HMO, PPO, POS, and EPO
Rationale: MCOs are structured as Health Maintenance Organizations, Preferred Provider
Organizations, Point of Service organizations, and Exclusive Provider Organizations.
Question 5
Which of the following describes a government-sponsored health coverage plan?
A) Exclusive Provider Organization (EPO)
B) High-Deductible Health Plan (HDHP)
C) Medicare Managed Care (Medicare Advantage)
D) Fully insured employer-based PPO
E) Self-funded ERISA plan
Correct Answer: C) Medicare Managed Care (Medicare Advantage)
Rationale: Government-sponsored plans include Medicare (Parts A-D), Medicaid, and the
managed care versions of both, such as Medicare Advantage.
Question 6
What is identified as a key driver of increasing healthcare costs in the United States?
A) Decreasing life expectancy among the general population
B) Provider payment systems that reward volume over quality and outcomes
C) A shift toward perfectly healthy lifestyle choices by all consumers
D) Increased transparency in hospital supply chain pricing
E) Reductions in health plan administrative fees
Correct Answer: B) Provider payment systems that reward volume over quality and
outcomes
Rationale: Cost drivers include demographics, chronic conditions, provider payment
systems focused on volume, consumer perceptions, and supply chain expenses.
Question 7
In a Health Maintenance Organization (HMO), what is a requirement for a patient to have their
services covered?
A) They must seek care from any provider in the state
B) They must use an in-network provider and typically require a PCP referral
C) They must pay a separate deductible for every specialist visit
D) They must be enrolled in Medicare Part A
E) They must be employed by a company with fewer than 25 employees
Correct Answer: B) They must use an in-network provider and typically require a PCP
referral
, 3
Rationale: HMOs are characterized by the use of a Primary Care Physician (PCP), the
requirement for referrals to see specialists, and the mandate to use in-network providers
for coverage.
Question 8
Medicare Part A provides coverage for which type of service?
A) Outpatient physician office visits
B) Prescription drugs through private pharmacies
C) Inpatient hospital, hospice, and skilled nursing coverage
D) Long-term custodial nursing home care
E) Routine dental and vision examinations
Correct Answer: C) Inpatient hospital, hospice, and skilled nursing coverage
Rationale: Medicare Part A is specifically dedicated to inpatient/hospital care, skilled
nursing facilities, and hospice services.
Question 9
Medicare Part B is designed to cover which of the following?
A) Inpatient surgical stays
B) Home health care exclusively
C) Outpatient and medical coverage
D) Medicare Advantage supplemental benefits
E) Prescription drug manufacturing costs
Correct Answer: C) Outpatient and medical coverage
Rationale: Medicare Part B provides coverage for medically necessary services like doctors'
services and outpatient care.
Question 10
Medicare Advantage plans are also known as:
A) Medicare Part A
B) Medicare Part B
C) Medicare Part C
D) Medicare Part D
E) Medigap
Correct Answer: C) Medicare Part C
Rationale: Medicare Part C is an alternative way to receive Medicare benefits through
private managed care plans known as Medicare Advantage.
Question 11
Which part of Medicare provides prescription drug coverage?
A) Part A
B) Part B
, 4
C) Part C
D) Part D
E) Part E
Correct Answer: D) Part D
Rationale: Medicare Part D was established to provide prescription drug benefits to
Medicare beneficiaries.
Question 12
The HMO Act of 1973 required for-profit companies with 25 or more employees to:
A) Eliminate all private insurance options
B) Provide free healthcare to all dependents of employees
C) Offer a "dual choice" by making HMO plans available alongside traditional plans
D) Pay a fine if they did not utilize capitated payment models
E) Directly contract with the federal government for healthcare
Correct Answer: C) Offer a "dual choice" by making HMO plans available alongside
traditional plans
Rationale: The 1973 Act mandated that certain employers offer federally qualified HMOs as
an option to their employees, fostering the growth of managed care.
Question 13
Which statement is TRUE regarding Advance Beneficiary Notices (ABNs)?
A) They are required for every service a patient receives, regardless of coverage.
B) They notify the patient that a specific service may not be covered by Medicare.
C) They are only used in Medicaid managed care plans.
D) They guarantee that Medicare will pay for the service if signed.
E) They are used to bill the patient for services that are never covered by Medicare.
Correct Answer: B) They notify the patient that a specific service may not be covered by
Medicare.
Rationale: An ABN notifies the patient before receiving a service that Medicare may not
cover it, allowing the patient to decide whether to proceed and pay out of pocket.
Question 14
How is the Medical Loss Ratio (MLR) calculated?
A) Total Premiums divided by Total Medical Expenses
B) Total Medical Expenses divided by Total Premiums
C) Administrative Costs divided by Net Income
D) Total Claims minus Total Deductibles
E) Inpatient Costs divided by Outpatient Revenue
Correct Answer: B) Total Medical Expenses divided by Total Premiums
Rationale: The MLR represents the percentage of premium dollars an insurer spends on
medical claims and quality improvement versus administrative costs.
