CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA)
2024-2025 REAL EXAM AND STUDY GUIDE 350
QUESTIONS WITH DETAILED VERIFIED ANSWERS
(100% CORRECT ANSWERS) /ALREADY GRADED A+
Which option is considered a key difference between inpatient and outpatient contracting? -
ANSWER--Reimbursement methodology differences
-Operational policies and procedures
-Market differences affecting outpatient and inpatient volumes
All of the following should be analyzed prior to and/or during contract negotiations, EXCEPT: -
ANSWER-Historical member premiums
All of the following should be analyzed prior to and/or during contract negotiations: - ANSWER-
-Member volumes by product type
-Historical reimbursement levels by product type
-Historical claims payment and/or submission problems
What is a clean claim? - ANSWER-A properly completed billing form
Which data is included in a termination provision in standard contracting? - ANSWER--What is
cause?
-What is termination Without Cause?
-Notice of termination
What is direct contracting? - ANSWER-A single-employer or multi-employer healthcare alliances
that contract directly with providers for healthcare services
,What is a non-directed PPO? - ANSWER-A payer that has contracted either directly or indirectly
with the provider to access preferred rates
All of the following are responsibilities of a provider organization's Board of Directors, EXCEPT: -
ANSWER-Implementation issues
All of the following are responsibilities of a provider organization's Board of Directors: -
ANSWER--Fiduciary matters
-Legal affairs
-Policy matters
Which of the following is required for claims processing? - ANSWER--Patient and/or enrollee ID,
age, and gender
-Type of diagnosis/major diagnostic category
-Date of service
Which of the following terms refers to information about any other health plan or carrier that
may share liability for healthcare expenses via a spouse's coverage or the like? - ANSWER-
Coordination of benefits (COB)
What is the function of electronic data interchange (EDI)? - ANSWER-To allow both healthcare
providers and payers to exchange common information required
What was the aim of advocacy groups initiated in the late 1990s? - ANSWER-To inform the
discussion about the quality of care and the value of benefit plans
Which of the following statements is true regarding The Leapfrog Group? - ANSWER-The
Leapfrog Group was started in the late 1990s to engage consumers and clinicians in the
discussion to improve care quality.
, Which option is included in the set of new value propositions and tools that emerged in the
early 2000s? - ANSWER--Product development focused on employee contribution strategies,
network access, and funding options.
-Medical management philosophies based on retrospective evaluation of care, rather than
prospective review and management.
-A proliferation of self-service technologies to reduce administrative costs.
Identify which option(s) is a benefit for CDHP consumers. - ANSWER--Coverage
-Choice
-Access
Identify which options are a benefit for HSA consumers. - ANSWER--It is transportable, allowing
workers access from one job to the next.
-Both employees and employers can contribute pretax dollars to the qualified account.
-They are available to everyone, not just employees of small businesses or the self-
employed.
What is an ACO? - ANSWER-A system of providers and facilities that can work in concert to care
for a given patient population
What is the purpose of the comprehension accreditation process? - ANSWER-To evaluate an
organization's compliance with the CMS COP standards and other accreditation requirements
What was the aim of the HMO Act of 1973? - ANSWER-To change the system of health care
delivery.
Steps used to control costs of managed care include: - ANSWER-Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
2024-2025 REAL EXAM AND STUDY GUIDE 350
QUESTIONS WITH DETAILED VERIFIED ANSWERS
(100% CORRECT ANSWERS) /ALREADY GRADED A+
Which option is considered a key difference between inpatient and outpatient contracting? -
ANSWER--Reimbursement methodology differences
-Operational policies and procedures
-Market differences affecting outpatient and inpatient volumes
All of the following should be analyzed prior to and/or during contract negotiations, EXCEPT: -
ANSWER-Historical member premiums
All of the following should be analyzed prior to and/or during contract negotiations: - ANSWER-
-Member volumes by product type
-Historical reimbursement levels by product type
-Historical claims payment and/or submission problems
What is a clean claim? - ANSWER-A properly completed billing form
Which data is included in a termination provision in standard contracting? - ANSWER--What is
cause?
-What is termination Without Cause?
-Notice of termination
What is direct contracting? - ANSWER-A single-employer or multi-employer healthcare alliances
that contract directly with providers for healthcare services
,What is a non-directed PPO? - ANSWER-A payer that has contracted either directly or indirectly
with the provider to access preferred rates
All of the following are responsibilities of a provider organization's Board of Directors, EXCEPT: -
ANSWER-Implementation issues
All of the following are responsibilities of a provider organization's Board of Directors: -
ANSWER--Fiduciary matters
-Legal affairs
-Policy matters
Which of the following is required for claims processing? - ANSWER--Patient and/or enrollee ID,
age, and gender
-Type of diagnosis/major diagnostic category
-Date of service
Which of the following terms refers to information about any other health plan or carrier that
may share liability for healthcare expenses via a spouse's coverage or the like? - ANSWER-
Coordination of benefits (COB)
What is the function of electronic data interchange (EDI)? - ANSWER-To allow both healthcare
providers and payers to exchange common information required
What was the aim of advocacy groups initiated in the late 1990s? - ANSWER-To inform the
discussion about the quality of care and the value of benefit plans
Which of the following statements is true regarding The Leapfrog Group? - ANSWER-The
Leapfrog Group was started in the late 1990s to engage consumers and clinicians in the
discussion to improve care quality.
, Which option is included in the set of new value propositions and tools that emerged in the
early 2000s? - ANSWER--Product development focused on employee contribution strategies,
network access, and funding options.
-Medical management philosophies based on retrospective evaluation of care, rather than
prospective review and management.
-A proliferation of self-service technologies to reduce administrative costs.
Identify which option(s) is a benefit for CDHP consumers. - ANSWER--Coverage
-Choice
-Access
Identify which options are a benefit for HSA consumers. - ANSWER--It is transportable, allowing
workers access from one job to the next.
-Both employees and employers can contribute pretax dollars to the qualified account.
-They are available to everyone, not just employees of small businesses or the self-
employed.
What is an ACO? - ANSWER-A system of providers and facilities that can work in concert to care
for a given patient population
What is the purpose of the comprehension accreditation process? - ANSWER-To evaluate an
organization's compliance with the CMS COP standards and other accreditation requirements
What was the aim of the HMO Act of 1973? - ANSWER-To change the system of health care
delivery.
Steps used to control costs of managed care include: - ANSWER-Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
