CSPR - Certified Specialist Payment Rep
(HFMA) EXAM STUDY GUIDE | ACCURATE
QUESTIONS AND ANSWERS (VERIFIED
ANSWERS) | LATEST (2026/2027) UPDATED
VERSION | 100% GUARANTEED PASS
{JUST RELEASED}
1. Steps used to control costs of managed care include: - ANSWER ✓
Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
2. DRG is used to classify - ANSWER ✓ 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 types of private health plan coverage - ANSWER
✓ 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.
4. Managed care organizations (MCO) exist primarily in four forms: -
ANSWER ✓ Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
5. Identify the various types of government‐sponsored health coverage: -
ANSWER ✓ Medicare - Government; Beneficiaries enrolled in such
plans, but, participation in these
plans is voluntary.
Medicaid
6. 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)
7. Identify some key drivers of increasing healthcare costs - ANSWER
✓ 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
8. Health Maintenance Organizations (HMO) - ANSWER ✓ 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)
9. Medicare is composed of four parts: - ANSWER ✓ 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
, 10. HMO Act of 1973 - ANSWER ✓ 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.
11. Which of the following statements regarding employer-based health
insurance in the United States is true? - ANSWER ✓ The real advent
of employer-based insurance came through Blue Cross, which was
started by hospital associations during the Depression.
12. The Health Maintenance Organization (HMO) Act of 1973 gave
qualified HMOs the right to "mandate" an employer under certain
conditions, meaning employers: - ANSWER ✓ Would have to offer
HMO plans along side traditional fee-for-service medical plans.
13. Which of the following is an anticipated change in the relationships
between consumers and providers? - ANSWER ✓ Providers will face
many new service demands and consumers will have virtually
unfettered access to those services
14. What transition began as a result of the March 2010 healthcare reform
legislation? - ANSWER ✓ A transition toward new models of health
care delivery with corresponding changes system financing and
provider reimbursement.
(HFMA) EXAM STUDY GUIDE | ACCURATE
QUESTIONS AND ANSWERS (VERIFIED
ANSWERS) | LATEST (2026/2027) UPDATED
VERSION | 100% GUARANTEED PASS
{JUST RELEASED}
1. Steps used to control costs of managed care include: - ANSWER ✓
Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
2. DRG is used to classify - ANSWER ✓ 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 types of private health plan coverage - ANSWER
✓ 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.
4. Managed care organizations (MCO) exist primarily in four forms: -
ANSWER ✓ Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
5. Identify the various types of government‐sponsored health coverage: -
ANSWER ✓ Medicare - Government; Beneficiaries enrolled in such
plans, but, participation in these
plans is voluntary.
Medicaid
6. 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)
7. Identify some key drivers of increasing healthcare costs - ANSWER
✓ 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
8. Health Maintenance Organizations (HMO) - ANSWER ✓ 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)
9. Medicare is composed of four parts: - ANSWER ✓ 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
, 10. HMO Act of 1973 - ANSWER ✓ 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.
11. Which of the following statements regarding employer-based health
insurance in the United States is true? - ANSWER ✓ The real advent
of employer-based insurance came through Blue Cross, which was
started by hospital associations during the Depression.
12. The Health Maintenance Organization (HMO) Act of 1973 gave
qualified HMOs the right to "mandate" an employer under certain
conditions, meaning employers: - ANSWER ✓ Would have to offer
HMO plans along side traditional fee-for-service medical plans.
13. Which of the following is an anticipated change in the relationships
between consumers and providers? - ANSWER ✓ Providers will face
many new service demands and consumers will have virtually
unfettered access to those services
14. What transition began as a result of the March 2010 healthcare reform
legislation? - ANSWER ✓ A transition toward new models of health
care delivery with corresponding changes system financing and
provider reimbursement.
