CSPR - Certified Specialist Payment Rep
(HFMA) Exam with Questions and
Correct Answers Latest 2025 GRADED
A+
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.
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
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
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 ,ANSWER-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 ,ANSWER-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
,ANSWER-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 ,ANSWER--Risk
,pooling
-Capitalization
-Network ,management
Which ,of ,the ,following ,is ,a ,service ,provided ,by ,a ,well-managed ,third-party
,administrator ,(TPA)? ,- ,CORRECT ,ANSWER--Administrative
-Utilization ,review ,(UR) ,
-Claims ,processing
What ,is ,tiering? ,- ,CORRECT ,ANSWER-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
,ANSWER--Making ,advance ,payment ,to ,providers ,for ,all ,services ,needed ,to
,care ,for ,a ,member
(HFMA) Exam with Questions and
Correct Answers Latest 2025 GRADED
A+
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.
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
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
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 ,ANSWER-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 ,ANSWER-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
,ANSWER-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 ,ANSWER--Risk
,pooling
-Capitalization
-Network ,management
Which ,of ,the ,following ,is ,a ,service ,provided ,by ,a ,well-managed ,third-party
,administrator ,(TPA)? ,- ,CORRECT ,ANSWER--Administrative
-Utilization ,review ,(UR) ,
-Claims ,processing
What ,is ,tiering? ,- ,CORRECT ,ANSWER-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
,ANSWER--Making ,advance ,payment ,to ,providers ,for ,all ,services ,needed ,to
,care ,for ,a ,member
