CSPR - Certified Specialist Payment Rep
(HFMA) Exam Question and Answers 2025
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: - ansCapitation
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 - ansAlthough 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
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,website of your local Medicare carrier.
Aligning incentives has come to mean _________. - ansThe 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: - ansDetailed 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: -
ansImplementation 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: -
ansHistorical 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? - ansContract standardization
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, 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).
Catastrophic Case Management - ansused to manage diseases associated with very high costs of care.
Clear implications for CDHP consumers include the following: - ans-More Financial Burden-CDHPs shift
greater premium percentages to the consumer and have higher copayments, deductibles, and stop-loss
thresholds than traditional managed care plans.
-Accountability for Healthcare Use-Some plans offer members points for life style behaviors that support
better health (points for nonsmokers, exercise, etc.).
-Shopping for Health Care-Consumers are incentivized to research the most appropriate healthcare
provider. Many payer websites now have financial calculators to help consumers determine what their
cost will be under their benefit plan.
-Record Keeping - Consumers may be required to track claims and payments to account for out-of-pocket
costs, copayments, and deductible thresholds. In addition, the HRA component and stop-loss coverage
add further complexity. Many of the CDHPs have tools to help members track claims, but this may be a
burden for consumers to bear.
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(HFMA) Exam Question and Answers 2025
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: - ansCapitation
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 - ansAlthough 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
P a g e 1 | 23
,website of your local Medicare carrier.
Aligning incentives has come to mean _________. - ansThe 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: - ansDetailed 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: -
ansImplementation 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: -
ansHistorical 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? - ansContract standardization
P a g e 2 | 23
, 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).
Catastrophic Case Management - ansused to manage diseases associated with very high costs of care.
Clear implications for CDHP consumers include the following: - ans-More Financial Burden-CDHPs shift
greater premium percentages to the consumer and have higher copayments, deductibles, and stop-loss
thresholds than traditional managed care plans.
-Accountability for Healthcare Use-Some plans offer members points for life style behaviors that support
better health (points for nonsmokers, exercise, etc.).
-Shopping for Health Care-Consumers are incentivized to research the most appropriate healthcare
provider. Many payer websites now have financial calculators to help consumers determine what their
cost will be under their benefit plan.
-Record Keeping - Consumers may be required to track claims and payments to account for out-of-pocket
costs, copayments, and deductible thresholds. In addition, the HRA component and stop-loss coverage
add further complexity. Many of the CDHPs have tools to help members track claims, but this may be a
burden for consumers to bear.
P a g e 3 | 23
