CSPR - Certified Specialist Payment Rep
(HFMA)2026 EXAM QUESTIONS AND
VERIFIED
ANSWERS (GRADED A+) DETAILED
ANSWERS| pdf
Which of the following statements regarding employer-based
health insurance in the United States is true?
The real advent of employer-based insurance came through Blue
Cross, which was started by hospital associations during the
Depression.
Provider service organizations (PSOs) function like health
maintenance organizations (HMOs) in all of the following
ways:
-Risk pooling
-Capitalization
-Network management
Which of the following is a service provided by a well-
managed third-party administrator (TPA)?
-Administrative
-Utilization review
(UR) -Claims
processing What is
tiering?
,The ranking or classifying of one or more of the provider delivery
system components
Which option is a practice used to control costs of managed
care?
-Making advance payment to providers for all services needed to
care for a member
-Combining services provided and bundling the associated
charges
-Agreement between the payer and provider on reasonable
payment for each service.
Which option is a risk involved in per diem payments?
-The risk to the insurance company or health plan
-The risk to the hospital
-The risk when embracing per diem payments in complex case
Diagnosis-related group (DRG) is:
A payment category
How is the term carve-out used when discussing managed
care?
To refer to specific benefits or services
What is the term Coordination of Benefits (COB)?
A term used to describe how payment is coordinated for patients
who have coverage through two insurance policies
Which three components are used to determine the total RVU
value for a service?
-Malpractice expense
-Lowest market price for services used -
Medicare discounts
,The Health Maintenance Organization (HMO) Act of 1973
gave qualified HMOs the right to "mandate" an employer
under certain conditions, meaning employers:
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?
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?
A transition toward new models of health care delivery with
corresponding changes system financing and provider
reimbursement.
Which statement is false concerning ABNs?
ABN began establishing new requirements for managed care
plans participating in the Medicare program.
Which Statement is TRUE concerning ABNs?
-ABNs are not required for services that are never covered by
Medicare. -An ABN form notifies the patient before he or she
receives the service that it may not be covered by Medicare
and that he or she will need to pay out of pocket.
-Although ABNs can have significant financial implications for the
physician, they also serve an important fraud and abuse
compliance function.
What is the overall function of Medicaid?
, The pay for medical assistance for certain individuals and low-
income families Medical Cost Ratio (MCR) or Medical Loss
Ratio (MLR) is defined as:
As the healthcare industry moves to control growth in
medical spending, what initiative can NOT help hospitals
maintain their margins?
-Pay-for-performance programs
-Health savings accounts
-Price transparency
Identify which initiatives are focused on in an effort to help
increase an organization's revenue/profit /margins.
-Health plan consolidation
-Payment policing and standardization of contract requirements
-Shift in volume and cost risk to
hospitals -Contract performance
modeling What are rating tiers?
Different rates charged on the basis of the number and
relationships What is the role of reinsurance?
Reinsurance seeks to limit a policyholder's liability for catastrophic
claims Which option is a major trend in case management?
-Shift from broad-based toward more focused efforts
-Reduction of administrative costs -
Greater physician involvement
What type of provider authorization is applied in emergency
cases, where prior authorization is impossible?
Concurrent
(HFMA)2026 EXAM QUESTIONS AND
VERIFIED
ANSWERS (GRADED A+) DETAILED
ANSWERS| pdf
Which of the following statements regarding employer-based
health insurance in the United States is true?
The real advent of employer-based insurance came through Blue
Cross, which was started by hospital associations during the
Depression.
Provider service organizations (PSOs) function like health
maintenance organizations (HMOs) in all of the following
ways:
-Risk pooling
-Capitalization
-Network management
Which of the following is a service provided by a well-
managed third-party administrator (TPA)?
-Administrative
-Utilization review
(UR) -Claims
processing What is
tiering?
,The ranking or classifying of one or more of the provider delivery
system components
Which option is a practice used to control costs of managed
care?
-Making advance payment to providers for all services needed to
care for a member
-Combining services provided and bundling the associated
charges
-Agreement between the payer and provider on reasonable
payment for each service.
Which option is a risk involved in per diem payments?
-The risk to the insurance company or health plan
-The risk to the hospital
-The risk when embracing per diem payments in complex case
Diagnosis-related group (DRG) is:
A payment category
How is the term carve-out used when discussing managed
care?
To refer to specific benefits or services
What is the term Coordination of Benefits (COB)?
A term used to describe how payment is coordinated for patients
who have coverage through two insurance policies
Which three components are used to determine the total RVU
value for a service?
-Malpractice expense
-Lowest market price for services used -
Medicare discounts
,The Health Maintenance Organization (HMO) Act of 1973
gave qualified HMOs the right to "mandate" an employer
under certain conditions, meaning employers:
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?
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?
A transition toward new models of health care delivery with
corresponding changes system financing and provider
reimbursement.
Which statement is false concerning ABNs?
ABN began establishing new requirements for managed care
plans participating in the Medicare program.
Which Statement is TRUE concerning ABNs?
-ABNs are not required for services that are never covered by
Medicare. -An ABN form notifies the patient before he or she
receives the service that it may not be covered by Medicare
and that he or she will need to pay out of pocket.
-Although ABNs can have significant financial implications for the
physician, they also serve an important fraud and abuse
compliance function.
What is the overall function of Medicaid?
, The pay for medical assistance for certain individuals and low-
income families Medical Cost Ratio (MCR) or Medical Loss
Ratio (MLR) is defined as:
As the healthcare industry moves to control growth in
medical spending, what initiative can NOT help hospitals
maintain their margins?
-Pay-for-performance programs
-Health savings accounts
-Price transparency
Identify which initiatives are focused on in an effort to help
increase an organization's revenue/profit /margins.
-Health plan consolidation
-Payment policing and standardization of contract requirements
-Shift in volume and cost risk to
hospitals -Contract performance
modeling What are rating tiers?
Different rates charged on the basis of the number and
relationships What is the role of reinsurance?
Reinsurance seeks to limit a policyholder's liability for catastrophic
claims Which option is a major trend in case management?
-Shift from broad-based toward more focused efforts
-Reduction of administrative costs -
Greater physician involvement
What type of provider authorization is applied in emergency
cases, where prior authorization is impossible?
Concurrent
