CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA)
UPDATED EXAMS WITH ACCURATE SOLUTIONS
2026/2027/ GRADED A+
A fixed payment amount based upon the number of members assigned to a provider, and
does not vary based upon the number of services rendered, is known as: - ANS ✅✅-
Capitation
According to MedPAC, which option is a benefit or undesirable consequence of bundling
payments? - ANS ✅✅--It allows Medicare to pay a set fee per hospitalization episode.
-It would provide the potential to improve efficiency and quality
-It would lead to underutilization of services
Advanced Beneficiary Notice (ABN): Potential Service Denials - ANS ✅✅-Although typically
covered by Medicare, the following services are likely to be denied for lack of medical
necessity under the circumstances described below:
-Lab Tests - Lab tests (for example, complete blood count) when the diagnosis code does
not support Medicare's definition of medical necessity.
-Pap Smear - A screening Pap smear and pelvic exam given more often than every two years,
unless the beneficiary is in a category for which annual exams are covered
-Screening Fecal Occult Blood Test - A screening fecal occult blood test given more often
than annually or if the beneficiary is younger than 50 years
-Screening flexible sigmoidoscopy - A screening flexible sigmoidoscopy given more often
than every four years or if the beneficiary is younger than 45 years
-Prostate Cancer Screening - A prostate cancer screening test given more often than
annually or if the beneficiary is younger than 50 years
-Tetanus vaccine - A tetanus vaccine given prophylactically (as compared to one given
,because the patient stepped on a rusty nail)
-Local Medical Review Policy (LMRP) - Any service that does not meet the coverage criteria
established in Local Medical Review Policy (LMRP). Some Medicare carriers have established
specific coverage criteria. For example, some carriers have established LMRPs for common
office procedures such as removal of benign skin lesions. You can find LMRPs through the
website of your local Medicare carrier.
Aligning incentives has come to mean _________. - ANS ✅✅-The appropriate addition of
some risk in the exchange of health care to a patient for some form of remuneration.
All of the following are effective contract evaluation criteria, EXCEPT: - ANS ✅✅-Detailed
contract performance assessments
All of the following are effective contract evaluation criteria: - ANS ✅✅--General payer or
provider criteria
-Reimbursement levels and parameters
-Provider costs and responsibilities
All of the following are responsibilities of a provider organization's Board of Directors, EXCEPT:
- ANS ✅✅-Implementation issues
All of the following are responsibilities of a provider organization's Board of Directors: - ANS
✅✅--Fiduciary matters
-Legal affairs
-Policy matters
All of the following should be analyzed prior to and/or during contract negotiations, EXCEPT: -
ANS ✅✅-Historical member premiums
, All of the following should be analyzed prior to and/or during contract negotiations: - ANS
✅✅--Member volumes by product type
-Historical reimbursement levels by product type
-Historical claims payment and/or submission problems
As the healthcare industry moves to control growth in medical spending, what initiative can
help hospitals maintain their margins? - ANS ✅✅-Contract standardization
As the healthcare industry moves to control growth in medical spending, what initiative can
NOT help hospitals maintain their margins? - ANS ✅✅--Pay-for-performance programs
-Health savings accounts
-Price transparency
Base MS-DRG payment, hospitals receive adjusted reimbursement for the following
categories of costs: - ANS ✅✅--Cost Outliers - Cost Outliers are defined as cases involving
atypical lengths of
stay or atypical cost
-Transfer Policy - Reduced payments for short stay patients
-Direct/Indirect Medical Education - Direct and indirect costs of patient care associated with
operating approved graduate medical education program. Reimbursement is based on the
ratio of interns and residents to hospital beds (IRB).
-Disportionate Share - Hospitals that serve a significant indigent population may
qualify as a disproportionate share hospital and receive an additional amount
determined by a formula based on the percentage of Supplemental Security
Income (SSI) and Medicaid patients. Distribution of funds is based on the hospital's share of
national uncompensated care for all Medicare DSH hospitals.
-End-Stage Renal Disease - Payment is calculated using a formula that incorporates the weekly
cost of dialysis (composite rate).
UPDATED EXAMS WITH ACCURATE SOLUTIONS
2026/2027/ GRADED A+
A fixed payment amount based upon the number of members assigned to a provider, and
does not vary based upon the number of services rendered, is known as: - ANS ✅✅-
Capitation
According to MedPAC, which option is a benefit or undesirable consequence of bundling
payments? - ANS ✅✅--It allows Medicare to pay a set fee per hospitalization episode.
-It would provide the potential to improve efficiency and quality
-It would lead to underutilization of services
Advanced Beneficiary Notice (ABN): Potential Service Denials - ANS ✅✅-Although typically
covered by Medicare, the following services are likely to be denied for lack of medical
necessity under the circumstances described below:
-Lab Tests - Lab tests (for example, complete blood count) when the diagnosis code does
not support Medicare's definition of medical necessity.
-Pap Smear - A screening Pap smear and pelvic exam given more often than every two years,
unless the beneficiary is in a category for which annual exams are covered
-Screening Fecal Occult Blood Test - A screening fecal occult blood test given more often
than annually or if the beneficiary is younger than 50 years
-Screening flexible sigmoidoscopy - A screening flexible sigmoidoscopy given more often
than every four years or if the beneficiary is younger than 45 years
-Prostate Cancer Screening - A prostate cancer screening test given more often than
annually or if the beneficiary is younger than 50 years
-Tetanus vaccine - A tetanus vaccine given prophylactically (as compared to one given
,because the patient stepped on a rusty nail)
-Local Medical Review Policy (LMRP) - Any service that does not meet the coverage criteria
established in Local Medical Review Policy (LMRP). Some Medicare carriers have established
specific coverage criteria. For example, some carriers have established LMRPs for common
office procedures such as removal of benign skin lesions. You can find LMRPs through the
website of your local Medicare carrier.
Aligning incentives has come to mean _________. - ANS ✅✅-The appropriate addition of
some risk in the exchange of health care to a patient for some form of remuneration.
All of the following are effective contract evaluation criteria, EXCEPT: - ANS ✅✅-Detailed
contract performance assessments
All of the following are effective contract evaluation criteria: - ANS ✅✅--General payer or
provider criteria
-Reimbursement levels and parameters
-Provider costs and responsibilities
All of the following are responsibilities of a provider organization's Board of Directors, EXCEPT:
- ANS ✅✅-Implementation issues
All of the following are responsibilities of a provider organization's Board of Directors: - ANS
✅✅--Fiduciary matters
-Legal affairs
-Policy matters
All of the following should be analyzed prior to and/or during contract negotiations, EXCEPT: -
ANS ✅✅-Historical member premiums
, All of the following should be analyzed prior to and/or during contract negotiations: - ANS
✅✅--Member volumes by product type
-Historical reimbursement levels by product type
-Historical claims payment and/or submission problems
As the healthcare industry moves to control growth in medical spending, what initiative can
help hospitals maintain their margins? - ANS ✅✅-Contract standardization
As the healthcare industry moves to control growth in medical spending, what initiative can
NOT help hospitals maintain their margins? - ANS ✅✅--Pay-for-performance programs
-Health savings accounts
-Price transparency
Base MS-DRG payment, hospitals receive adjusted reimbursement for the following
categories of costs: - ANS ✅✅--Cost Outliers - Cost Outliers are defined as cases involving
atypical lengths of
stay or atypical cost
-Transfer Policy - Reduced payments for short stay patients
-Direct/Indirect Medical Education - Direct and indirect costs of patient care associated with
operating approved graduate medical education program. Reimbursement is based on the
ratio of interns and residents to hospital beds (IRB).
-Disportionate Share - Hospitals that serve a significant indigent population may
qualify as a disproportionate share hospital and receive an additional amount
determined by a formula based on the percentage of Supplemental Security
Income (SSI) and Medicaid patients. Distribution of funds is based on the hospital's share of
national uncompensated care for all Medicare DSH hospitals.
-End-Stage Renal Disease - Payment is calculated using a formula that incorporates the weekly
cost of dialysis (composite rate).
