5/15/25, 12:05 PM CSPR - Certified Specialist Payment Rep (HFMA) ACTUAL EXAM 2025 TEST COMPREHENSIVE QUESTIONS AND VERIF…
CSPR - Certified Specialist Payment Rep
(HFMA) ACTUAL EXAM 2025 TEST
COMPREHENSIVE QUESTIONS AND VERIFIED
ANSWERS (DETAILED & ELABORATED) 100%
SOLVED 2025!!
Save
Terms in this set (125)
Steps used to control Bundled codes
costs of managed care Capitation
include: Payer and Provider to agree on reasonable payment
Inpatient admissions for the purpose of reimbursing
hospitals for each case in a given category w/a
DRG is used to classify
negotiated fixed fee, regardless of the actual costs
incurred
HMO
Conventional
Identify the various types PPO and POS
of private health plan HDHP/SO plans - high-deductible health plans with
coverage a savings option; Private - Include higher patient
out-of-pocket expenditures for treatments that can
serve to reduce utilization/costs.
Managed care Health Maintenance Organizations (HMO)
organizations (MCO) Preferred Provider Organizations (PPO)
exist primarily in four Point of Service (POS) Organizations
forms: Exclusive Provider Organizations (EPO)
https://quizlet.com/1044334097/cspr-certified-specialist-payment-rep-hfma-actual-exam-2025-test-comprehensive-questions-and-verified-answer… 1/27
,5/15/25, 12:05 PM CSPR - Certified Specialist Payment Rep (HFMA) ACTUAL EXAM 2025 TEST COMPREHENSIVE QUESTIONS AND VERIF…
Medicare - Government; Beneficiaries enrolled in
such plans, but, participation in these
plans is voluntary.
Identify the various types
Medicaid
of government‐
Medicaid Managed Care - Medicaid beneficiaries
sponsored health
are required to select and enroll in a managed care
coverage:
plan.
Medicare Managed Care (a.k.a. Medicare
Advantage Plans)
Demographics
Chronic Conditions
Provider payment systems - Provider payment
Identify some key drivers systems that are designed to reward volume rather
of increasing healthcare than quality, outcomes, and prevention
costs Consumer Perceptions
Health Plan pressure
Physician Relationships
Supply Chain
Referrals
PCP
Health Maintenance Patients must use an in-network provider for their
Organizations (HMO) services to be covered.
Reimbursement - majority of services offered are
reimbursed through capitation payments (PMPM)
Part A - provides inpatient/hospital, hospice, and
skilled nursing coverage
Part B - provides outpatient/medical coverage
Medicare is composed of
Part C - an alternative way to receive your Medicare
four parts:
benefits (known as Medicare
Advantage)
Part D - prescription drug coverage
The HMO Act of 1973 gave federally qualified HMOs
the right to mandate that employers offer their
product to their employees under certain
HMO Act of 1973 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.
https://quizlet.com/1044334097/cspr-certified-specialist-payment-rep-hfma-actual-exam-2025-test-comprehensive-questions-and-verified-answer… 2/27
, 5/15/25, 12:05 PM CSPR - Certified Specialist Payment Rep (HFMA) ACTUAL EXAM 2025 TEST COMPREHENSIVE QUESTIONS AND VERIF…
Which of the following The real advent of employer-based insurance came
statements regarding through Blue Cross, which was started by hospital
employer-based health associations during the Depression.
insurance in the United
States is true?
The Health Maintenance Would have to offer HMO plans along side
Organization (HMO) Act traditional fee-for-service medical plans.
of 1973 gave qualified
HMOs the right to
"mandate" an employer
under certain conditions,
meaning employers:
Which of the following is Providers will face many new service demands and
an anticipated change in consumers will have virtually unfettered access to
the relationships those services
between consumers and
providers?
What transition began as A transition toward new models of health care
a result of the March 2010 delivery with corresponding changes system
healthcare reform financing and provider reimbursement.
legislation?
ABN began establishing new requirements for
Which statement is false
managed care plans participating in the Medicare
concerning ABNs?
program.
-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
Which Statement is TRUE covered by Medicare and that he or she will need to
concerning ABNs? 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 The pay for medical assistance for certain
function of Medicaid? individuals and low-income families
https://quizlet.com/1044334097/cspr-certified-specialist-payment-rep-hfma-actual-exam-2025-test-comprehensive-questions-and-verified-answer… 3/27
CSPR - Certified Specialist Payment Rep
(HFMA) ACTUAL EXAM 2025 TEST
COMPREHENSIVE QUESTIONS AND VERIFIED
ANSWERS (DETAILED & ELABORATED) 100%
SOLVED 2025!!
Save
Terms in this set (125)
Steps used to control Bundled codes
costs of managed care Capitation
include: Payer and Provider to agree on reasonable payment
Inpatient admissions for the purpose of reimbursing
hospitals for each case in a given category w/a
DRG is used to classify
negotiated fixed fee, regardless of the actual costs
incurred
HMO
Conventional
Identify the various types PPO and POS
of private health plan HDHP/SO plans - high-deductible health plans with
coverage a savings option; Private - Include higher patient
out-of-pocket expenditures for treatments that can
serve to reduce utilization/costs.
Managed care Health Maintenance Organizations (HMO)
organizations (MCO) Preferred Provider Organizations (PPO)
exist primarily in four Point of Service (POS) Organizations
forms: Exclusive Provider Organizations (EPO)
https://quizlet.com/1044334097/cspr-certified-specialist-payment-rep-hfma-actual-exam-2025-test-comprehensive-questions-and-verified-answer… 1/27
,5/15/25, 12:05 PM CSPR - Certified Specialist Payment Rep (HFMA) ACTUAL EXAM 2025 TEST COMPREHENSIVE QUESTIONS AND VERIF…
Medicare - Government; Beneficiaries enrolled in
such plans, but, participation in these
plans is voluntary.
Identify the various types
Medicaid
of government‐
Medicaid Managed Care - Medicaid beneficiaries
sponsored health
are required to select and enroll in a managed care
coverage:
plan.
Medicare Managed Care (a.k.a. Medicare
Advantage Plans)
Demographics
Chronic Conditions
Provider payment systems - Provider payment
Identify some key drivers systems that are designed to reward volume rather
of increasing healthcare than quality, outcomes, and prevention
costs Consumer Perceptions
Health Plan pressure
Physician Relationships
Supply Chain
Referrals
PCP
Health Maintenance Patients must use an in-network provider for their
Organizations (HMO) services to be covered.
Reimbursement - majority of services offered are
reimbursed through capitation payments (PMPM)
Part A - provides inpatient/hospital, hospice, and
skilled nursing coverage
Part B - provides outpatient/medical coverage
Medicare is composed of
Part C - an alternative way to receive your Medicare
four parts:
benefits (known as Medicare
Advantage)
Part D - prescription drug coverage
The HMO Act of 1973 gave federally qualified HMOs
the right to mandate that employers offer their
product to their employees under certain
HMO Act of 1973 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.
https://quizlet.com/1044334097/cspr-certified-specialist-payment-rep-hfma-actual-exam-2025-test-comprehensive-questions-and-verified-answer… 2/27
, 5/15/25, 12:05 PM CSPR - Certified Specialist Payment Rep (HFMA) ACTUAL EXAM 2025 TEST COMPREHENSIVE QUESTIONS AND VERIF…
Which of the following The real advent of employer-based insurance came
statements regarding through Blue Cross, which was started by hospital
employer-based health associations during the Depression.
insurance in the United
States is true?
The Health Maintenance Would have to offer HMO plans along side
Organization (HMO) Act traditional fee-for-service medical plans.
of 1973 gave qualified
HMOs the right to
"mandate" an employer
under certain conditions,
meaning employers:
Which of the following is Providers will face many new service demands and
an anticipated change in consumers will have virtually unfettered access to
the relationships those services
between consumers and
providers?
What transition began as A transition toward new models of health care
a result of the March 2010 delivery with corresponding changes system
healthcare reform financing and provider reimbursement.
legislation?
ABN began establishing new requirements for
Which statement is false
managed care plans participating in the Medicare
concerning ABNs?
program.
-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
Which Statement is TRUE covered by Medicare and that he or she will need to
concerning ABNs? 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 The pay for medical assistance for certain
function of Medicaid? individuals and low-income families
https://quizlet.com/1044334097/cspr-certified-specialist-payment-rep-hfma-actual-exam-2025-test-comprehensive-questions-and-verified-answer… 3/27
