CSPR - Certified Specialist Payment Rep
(HFMA) Exam Questions and Answers with
Verified Solutions | Latest Updated 2026
Steps used to control costs of Bundled codes
managed care include: Capitation
Payer and Provider to agree on
reasonable
payment
DRG is used to classify 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 HMO
health plan coverage 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 Health Maintenance Organizations (HMO)
(MCO) Preferred Provider Organizations (PPO)
exist primarily in four forms: Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Identify the various types of Medicare - Government; Beneficiaries
government■sponsored health enrolled in
coverage: 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 Demographics
increasing healthcare costs 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 Referrals
(HMO) 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 Part A - provides inpatient/hospital,
parts: 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 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 The real advent of employer-based
regarding employer-based health insurance
insurance in the United States is came through Blue Cross, which was
true? started by
hospital associations during the
Depression.
The Health Maintenance Would have to offer HMO plans along side
Organization (HMO) Act of 1973 traditional fee-for-service medical plans.
gave qualified HMOs the right to
"mandate" an employer under
certain
conditions, meaning employers:
Which of the following is an Providers will face many new service
anticipated change in the demands and
relationships between consumers consumers will have virtually unfettered
and providers? access to
those services
What transition began as a result A transition toward new models of health
of care
the March 2010 healthcare reform delivery with corresponding changes
legislation? system
financing and provider reimbursement.
Which statement is false ABN began establishing new requirements
concerning for
ABNs? managed care plans participating in the
Medicare
program.
(HFMA) Exam Questions and Answers with
Verified Solutions | Latest Updated 2026
Steps used to control costs of Bundled codes
managed care include: Capitation
Payer and Provider to agree on
reasonable
payment
DRG is used to classify 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 HMO
health plan coverage 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 Health Maintenance Organizations (HMO)
(MCO) Preferred Provider Organizations (PPO)
exist primarily in four forms: Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Identify the various types of Medicare - Government; Beneficiaries
government■sponsored health enrolled in
coverage: 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 Demographics
increasing healthcare costs 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 Referrals
(HMO) 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 Part A - provides inpatient/hospital,
parts: 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 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 The real advent of employer-based
regarding employer-based health insurance
insurance in the United States is came through Blue Cross, which was
true? started by
hospital associations during the
Depression.
The Health Maintenance Would have to offer HMO plans along side
Organization (HMO) Act of 1973 traditional fee-for-service medical plans.
gave qualified HMOs the right to
"mandate" an employer under
certain
conditions, meaning employers:
Which of the following is an Providers will face many new service
anticipated change in the demands and
relationships between consumers consumers will have virtually unfettered
and providers? access to
those services
What transition began as a result A transition toward new models of health
of care
the March 2010 healthcare reform delivery with corresponding changes
legislation? system
financing and provider reimbursement.
Which statement is false ABN began establishing new requirements
concerning for
ABNs? managed care plans participating in the
Medicare
program.
