Page |1
CSPR - Certified Specialist Payment Rep
(HFMA) Questions and Correct Answers/
Latest Update / Already Graded
Steps used to control costs of managed care include:
Ans: Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify
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
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.
All rights reserved © 2025/ 2026 |
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Managed care organizations (MCO) exist primarily in four forms:
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:
Ans: 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
Ans: Demographics
Chronic Conditions
Provider payment systems - Provider payment systems that are
designed to reward volume rather than quality, outcomes, and
prevention
Consumer Perceptions
All rights reserved © 2025/ 2026 |
, Page |3
Health Plan pressure
Physician Relationships
Supply Chain
Health Maintenance Organizations (HMO)
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:
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
All rights reserved © 2025/ 2026 |
, Page |4
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?
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:
Ans: 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?
All rights reserved © 2025/ 2026 |
CSPR - Certified Specialist Payment Rep
(HFMA) Questions and Correct Answers/
Latest Update / Already Graded
Steps used to control costs of managed care include:
Ans: Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify
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
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.
All rights reserved © 2025/ 2026 |
, Page |2
Managed care organizations (MCO) exist primarily in four forms:
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:
Ans: 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
Ans: Demographics
Chronic Conditions
Provider payment systems - Provider payment systems that are
designed to reward volume rather than quality, outcomes, and
prevention
Consumer Perceptions
All rights reserved © 2025/ 2026 |
, Page |3
Health Plan pressure
Physician Relationships
Supply Chain
Health Maintenance Organizations (HMO)
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:
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
All rights reserved © 2025/ 2026 |
, Page |4
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?
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:
Ans: 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?
All rights reserved © 2025/ 2026 |
