CSPR - CERTIFIED SPECIALIST PAYMENT REP
(HFMA) EXAM QUESTIONS AND ANSWERS
2025/2026
Which statement is false concerning ABNs? - ANSWER >ABN began
establishing new requirements for managed care plans participating in
the Medicare program.
Which Statement is TRUE concerning ABNs? - 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? - 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: -
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: - 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: - ANSWER ->-Risk
pooling
-Capitalization
-Network management
Which of the following is a service provided by a wellmanaged third-
party administrator (TPA)? - ANSWER ->Administrative
-Utilization review (UR)
-Claims processing
What is tiering? - 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? -
ANSWER ->-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? - ANSWER ->-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: - ANSWER ->A payment category
How is the term carve-out used when discussing managed care? -
ANSWER ->To refer to specific benefits or services
,What is the term Coordination of Benefits (COB)? - ANSWER ->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? - ANSWER ->-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: - ANSWER ->Capitation
Aligning incentives has come to mean _________. - ANSWER ->The
appropriate addition of some risk in the exchange of health care to a
patient for some form of remuneration.
According to MedPAC, which option is a benefit or undesirable
consequence of bundling payments? - ANSWER ->-It allows Medicare
to pay a set fee per hospitalization episode.
-It would provide the potential to improve efficiency and quality
-It would lead to underutilization of services
As the healthcare industry moves to control growth in medical
spending, what initiative can help hospitals maintain their margins? -
ANSWER ->Contract standardization
As the healthcare industry moves to control growth in medical
spending, what initiative can NOT help hospitals maintain their
, margins? - ANSWER ->-Pay-forperformance programs -Health savings
accounts
-Price transparency
Identify which initiatives are focused on in an effort to help increase an
organization's revenue/profit /margins.
- ANSWER ->-Health plan consolidation
-Payment policing and standardization of contract requirements
-Shift in volume and cost risk to hospitals
-Contract performance modeling
What are rating tiers? - ANSWER ->Different rates charged on the basis
of the number and relationships
What is the role of reinsurance? - ANSWER -
>Reinsurance seeks to limit a policyholder's liability for catastrophic
claims
Which option is a major trend in case management? - ANSWER ->-Shift
from broad-based toward more focused efforts
-Reduction of administrative costs
-Greater physician involvement
What type of provider authorization is applied in emergency cases,
where prior authorization is impossible? - ANSWER ->Concurrent
What is utilization management (UM)? - ANSWER ->A tool to control
the costs of providing healthcare services to enrollees
(HFMA) EXAM QUESTIONS AND ANSWERS
2025/2026
Which statement is false concerning ABNs? - ANSWER >ABN began
establishing new requirements for managed care plans participating in
the Medicare program.
Which Statement is TRUE concerning ABNs? - 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? - 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: -
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: - 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: - ANSWER ->-Risk
pooling
-Capitalization
-Network management
Which of the following is a service provided by a wellmanaged third-
party administrator (TPA)? - ANSWER ->Administrative
-Utilization review (UR)
-Claims processing
What is tiering? - 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? -
ANSWER ->-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? - ANSWER ->-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: - ANSWER ->A payment category
How is the term carve-out used when discussing managed care? -
ANSWER ->To refer to specific benefits or services
,What is the term Coordination of Benefits (COB)? - ANSWER ->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? - ANSWER ->-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: - ANSWER ->Capitation
Aligning incentives has come to mean _________. - ANSWER ->The
appropriate addition of some risk in the exchange of health care to a
patient for some form of remuneration.
According to MedPAC, which option is a benefit or undesirable
consequence of bundling payments? - ANSWER ->-It allows Medicare
to pay a set fee per hospitalization episode.
-It would provide the potential to improve efficiency and quality
-It would lead to underutilization of services
As the healthcare industry moves to control growth in medical
spending, what initiative can help hospitals maintain their margins? -
ANSWER ->Contract standardization
As the healthcare industry moves to control growth in medical
spending, what initiative can NOT help hospitals maintain their
, margins? - ANSWER ->-Pay-forperformance programs -Health savings
accounts
-Price transparency
Identify which initiatives are focused on in an effort to help increase an
organization's revenue/profit /margins.
- ANSWER ->-Health plan consolidation
-Payment policing and standardization of contract requirements
-Shift in volume and cost risk to hospitals
-Contract performance modeling
What are rating tiers? - ANSWER ->Different rates charged on the basis
of the number and relationships
What is the role of reinsurance? - ANSWER -
>Reinsurance seeks to limit a policyholder's liability for catastrophic
claims
Which option is a major trend in case management? - ANSWER ->-Shift
from broad-based toward more focused efforts
-Reduction of administrative costs
-Greater physician involvement
What type of provider authorization is applied in emergency cases,
where prior authorization is impossible? - ANSWER ->Concurrent
What is utilization management (UM)? - ANSWER ->A tool to control
the costs of providing healthcare services to enrollees
