CSPR-Certified Specialist Payment Rep (HFMA).
ACTUAL 2025-2026 EXAM Questions and Answers
New Update.
Steps used to control costs of managed care include: - CORRECT ANS>>Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - CORRECT ANS>>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 ANS>>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.
Managed care organizations (MCO) exist primarily in four forms: - CORRECT ANS>>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 ANS>>Medicare -
Government; Beneficiaries enrolled in such plans, but, participation in these plans are 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 ANS>>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
Health Maintenance Organizations (HMO) - CORRECT ANS>>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 ANS>>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 ANS>>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 ANS>>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 ANS>>Would have to offer
HMO plans alongside traditional fee-for-service medical plans.
Which of the following is an anticipated change in the relationships between consumers and
providers? - CORRECT ANS>>Providers will face many new services 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 ANS>>A
transition toward new models of health care delivery with corresponding changes system financing
and provider reimbursement.
Which statement is false concerning ABNs? - CORRECT ANS>>ABN began establishing new
requirements for managed care plans participating in the Medicare program.
Which Statement is TRUE concerning ABNs? - CORRECT ANS>>-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
covered by Medicare and that he or she will need to 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 function of Medicaid? - CORRECT ANS>>The pay for medical assistance for certain
individuals and low-income families
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - CORRECT ANS>>Total Medical
Expenses divided by Total Premiums
Provider service organizations (PSOs) function like health maintenance organizations (HMOs) in all of
the following ways, EXCEPT: - CORRECT ANS>>Ties to the healthcare delivery industry rather than the
insurance industry
, Provider service organizations (PSOs) function like health maintenance organizations (HMOs) in all of
the following ways: - CORRECT ANS>>-Risk pooling
-Capitalization
-Network management
Which of the following is a service provided by a well-managed third- party administrator (TPA)? -
CORRECT ANS>>-Administrative
-Utilization review (UR)
-Claims processing
What is tiering? - CORRECT ANS>>The ranking or classifying of one or more of the provider delivery
system components
Which option is a practice used to control costs of managed care? - CORRECT ANS>>-Making advance
payment to providers for all services needed to care for a member
-Combining services provided and bundling the associated charges
-Agreement between the payer and provider on reasonable payment for each service.
Which option is a risk involved in per diem payments? - CORRECT ANS>>- The risk to the insurance
company or health plan
-The risk to the hospital
-The risk when embracing per diem payments in complex case
Diagnosis-related group (DRG) is: - CORRECT ANS>>A payment category
How is the term carving-out used when discussing managed care? - CORRECT ANS>>To refer to
specific benefits or services
What is the term Coordination of Benefits (COB)? - CORRECT ANS>>A term used to describe how
payment is coordinated for patients who have coverage through two insurance policies
Which three components are used to determine the total RVU value for a service? - CORRECT ANS>>-
Malpractice expense
-Lowest market price for services used
-Medicare discounts
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: - CORRECT ANS>>Capitation
ACTUAL 2025-2026 EXAM Questions and Answers
New Update.
Steps used to control costs of managed care include: - CORRECT ANS>>Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - CORRECT ANS>>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 ANS>>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.
Managed care organizations (MCO) exist primarily in four forms: - CORRECT ANS>>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 ANS>>Medicare -
Government; Beneficiaries enrolled in such plans, but, participation in these plans are 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 ANS>>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
Health Maintenance Organizations (HMO) - CORRECT ANS>>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 ANS>>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 ANS>>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 ANS>>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 ANS>>Would have to offer
HMO plans alongside traditional fee-for-service medical plans.
Which of the following is an anticipated change in the relationships between consumers and
providers? - CORRECT ANS>>Providers will face many new services 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 ANS>>A
transition toward new models of health care delivery with corresponding changes system financing
and provider reimbursement.
Which statement is false concerning ABNs? - CORRECT ANS>>ABN began establishing new
requirements for managed care plans participating in the Medicare program.
Which Statement is TRUE concerning ABNs? - CORRECT ANS>>-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
covered by Medicare and that he or she will need to 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 function of Medicaid? - CORRECT ANS>>The pay for medical assistance for certain
individuals and low-income families
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - CORRECT ANS>>Total Medical
Expenses divided by Total Premiums
Provider service organizations (PSOs) function like health maintenance organizations (HMOs) in all of
the following ways, EXCEPT: - CORRECT ANS>>Ties to the healthcare delivery industry rather than the
insurance industry
, Provider service organizations (PSOs) function like health maintenance organizations (HMOs) in all of
the following ways: - CORRECT ANS>>-Risk pooling
-Capitalization
-Network management
Which of the following is a service provided by a well-managed third- party administrator (TPA)? -
CORRECT ANS>>-Administrative
-Utilization review (UR)
-Claims processing
What is tiering? - CORRECT ANS>>The ranking or classifying of one or more of the provider delivery
system components
Which option is a practice used to control costs of managed care? - CORRECT ANS>>-Making advance
payment to providers for all services needed to care for a member
-Combining services provided and bundling the associated charges
-Agreement between the payer and provider on reasonable payment for each service.
Which option is a risk involved in per diem payments? - CORRECT ANS>>- The risk to the insurance
company or health plan
-The risk to the hospital
-The risk when embracing per diem payments in complex case
Diagnosis-related group (DRG) is: - CORRECT ANS>>A payment category
How is the term carving-out used when discussing managed care? - CORRECT ANS>>To refer to
specific benefits or services
What is the term Coordination of Benefits (COB)? - CORRECT ANS>>A term used to describe how
payment is coordinated for patients who have coverage through two insurance policies
Which three components are used to determine the total RVU value for a service? - CORRECT ANS>>-
Malpractice expense
-Lowest market price for services used
-Medicare discounts
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: - CORRECT ANS>>Capitation
