CSPR - Certified Specialist Payment Rep (HFMA) ACTUAL EXAM
2025 TEST COMPREHENSIVE QUESTIONS AND VERIFIED
ANSWERS (DETAILED & ELABORATED) 100% SOLVED 2025!!
Managed care organizations (MCO) exist primarily in four forms: - CORRECT
ANSWER-Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Identify the various types of government‐sponsored health coverage: - CORRECT
ANSWER-Medicare - Government; Beneficiaries enrolled in such plans, but,
participation in these
plans is voluntary.
Medicaid
Medicaid Managed Care - Medicaid beneficiaries are required to select and enroll
in a managed care plan.
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
,Identify some key drivers of increasing healthcare costs - CORRECT ANSWER-
Demographics
Chronic Conditions
Provider payment systems - Provider payment systems that are designed to
reward volume rather than quality, outcomes, and prevention
Consumer Perceptions
Health Plan pressure
Physician Relationships
Supply Chain
Steps used to control costs of managed care include: - CORRECT ANSWER-
Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - CORRECT ANSWER-Inpatient admissions for the
purpose of reimbursing hospitals for each case in a given category w/a negotiated
fixed fee, regardless of the actual costs incurred
Identify the various types of private health plan coverage - CORRECT ANSWER-
HMO
Conventional
PPO and POS
,HDHP/SO plans - high-deductible health plans with a savings option; Private -
Include higher patient out-of-pocket expenditures for treatments that can serve
to reduce utilization/costs.
Health Maintenance Organizations (HMO) - CORRECT ANSWER-Referrals
PCP
Patients must use an in-network provider for their services to be covered.
Reimbursement - majority of services offered are reimbursed through capitation
payments (PMPM)
Medicare is composed of four parts: - CORRECT ANSWER-Part A - provides
inpatient/hospital, hospice, and skilled nursing coverage
Part B - provides outpatient/medical coverage
Part C - an alternative way to receive your Medicare benefits (known as Medicare
Advantage)
Part D - prescription drug coverage
HMO Act of 1973 - CORRECT ANSWER-The HMO Act of 1973 gave federally
qualified HMOs the right to mandate that employers offer their product to their
employees under certain 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.
Which of the following statements regarding employer-based health insurance in
the United States is true? - CORRECT ANSWER-The real advent of employer-
, based insurance came through Blue Cross, which was started by hospital
associations during the Depression.
The Health Maintenance Organization (HMO) Act of 1973 gave qualified HMOs
the right to "mandate" an employer under certain conditions, meaning
employers: - CORRECT ANSWER-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? - CORRECT ANSWER-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? - CORRECT ANSWER-A transition toward new models of health care
delivery with corresponding changes system financing and provider
reimbursement.
Which statement is false concerning ABNs? - CORRECT ANSWER-ABN began
establishing new requirements for managed care plans participating in the
Medicare program.
Which Statement is TRUE concerning ABNs? - CORRECT ANSWER--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
2025 TEST COMPREHENSIVE QUESTIONS AND VERIFIED
ANSWERS (DETAILED & ELABORATED) 100% SOLVED 2025!!
Managed care organizations (MCO) exist primarily in four forms: - CORRECT
ANSWER-Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Identify the various types of government‐sponsored health coverage: - CORRECT
ANSWER-Medicare - Government; Beneficiaries enrolled in such plans, but,
participation in these
plans is voluntary.
Medicaid
Medicaid Managed Care - Medicaid beneficiaries are required to select and enroll
in a managed care plan.
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
,Identify some key drivers of increasing healthcare costs - CORRECT ANSWER-
Demographics
Chronic Conditions
Provider payment systems - Provider payment systems that are designed to
reward volume rather than quality, outcomes, and prevention
Consumer Perceptions
Health Plan pressure
Physician Relationships
Supply Chain
Steps used to control costs of managed care include: - CORRECT ANSWER-
Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - CORRECT ANSWER-Inpatient admissions for the
purpose of reimbursing hospitals for each case in a given category w/a negotiated
fixed fee, regardless of the actual costs incurred
Identify the various types of private health plan coverage - CORRECT ANSWER-
HMO
Conventional
PPO and POS
,HDHP/SO plans - high-deductible health plans with a savings option; Private -
Include higher patient out-of-pocket expenditures for treatments that can serve
to reduce utilization/costs.
Health Maintenance Organizations (HMO) - CORRECT ANSWER-Referrals
PCP
Patients must use an in-network provider for their services to be covered.
Reimbursement - majority of services offered are reimbursed through capitation
payments (PMPM)
Medicare is composed of four parts: - CORRECT ANSWER-Part A - provides
inpatient/hospital, hospice, and skilled nursing coverage
Part B - provides outpatient/medical coverage
Part C - an alternative way to receive your Medicare benefits (known as Medicare
Advantage)
Part D - prescription drug coverage
HMO Act of 1973 - CORRECT ANSWER-The HMO Act of 1973 gave federally
qualified HMOs the right to mandate that employers offer their product to their
employees under certain 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.
Which of the following statements regarding employer-based health insurance in
the United States is true? - CORRECT ANSWER-The real advent of employer-
, based insurance came through Blue Cross, which was started by hospital
associations during the Depression.
The Health Maintenance Organization (HMO) Act of 1973 gave qualified HMOs
the right to "mandate" an employer under certain conditions, meaning
employers: - CORRECT ANSWER-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? - CORRECT ANSWER-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? - CORRECT ANSWER-A transition toward new models of health care
delivery with corresponding changes system financing and provider
reimbursement.
Which statement is false concerning ABNs? - CORRECT ANSWER-ABN began
establishing new requirements for managed care plans participating in the
Medicare program.
Which Statement is TRUE concerning ABNs? - CORRECT ANSWER--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
