10/1/25, 12:04 PM CSPR - Certified Specialist Payment Rep (HFMA) Exam fully solved & updated 2025-2026(latest version verified for accuracy) | 2…
CSPR - Certified Specialist Payment Rep (HFMA)
Exam fully solved & updated 2025-2026(latest
version verified for accuracy) | 2024\2025 Latest!!
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Terms in this set (125)
Steps used to control Bundled codes
costs of managed care Capitation
include: Payer and Provider to agree on reasonable payment
Inpatient admissions for the purpose of reimbursing
hospitals for each case in a given category w/a
DRG is used to classify
negotiated fixed fee, regardless of the actual costs
incurred
HMO
Conventional
Identify the various types PPO and POS
of private health plan HDHP/SO plans - high-deductible health plans with a
coverage savings option; Private - Include higher patient out-
of-pocket expenditures for treatments that can serve
to reduce utilization/costs.
Health Maintenance Organizations (HMO)
Managed care
Preferred Provider Organizations (PPO)
organizations (MCO) exist
Point of Service (POS) Organizations
primarily in four forms:
Exclusive Provider Organizations (EPO)
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Medicare - Government; Beneficiaries enrolled in
such plans, but, participation in these
plans is voluntary.
Identify the various types
Medicaid
of government‐sponsored
Medicaid Managed Care - Medicaid beneficiaries are
health coverage:
required to select and enroll in a managed care plan.
Medicare Managed Care (a.k.a. Medicare Advantage
Plans)
Demographics
Chronic Conditions
Provider payment systems - Provider payment
Identify some key drivers systems that are designed to reward volume rather
of increasing healthcare than quality, outcomes, and prevention
costs Consumer Perceptions
Health Plan pressure
Physician Relationships
Supply Chain
Referrals
PCP
Health Maintenance Patients must use an in-network provider for their
Organizations (HMO) services to be covered.
Reimbursement - majority of services offered are
reimbursed through capitation payments (PMPM)
Part A - provides inpatient/hospital, hospice, and
skilled nursing coverage
Part B - provides outpatient/medical coverage
Medicare is composed of
Part C - an alternative way to receive your Medicare
four parts:
benefits (known as Medicare
Advantage)
Part D - prescription drug coverage
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, 10/1/25, 12:04 PM CSPR - Certified Specialist Payment Rep (HFMA) Exam fully solved & updated 2025-2026(latest version verified for accuracy) | 2…
The HMO Act of 1973 gave federally qualified HMOs
the right to mandate that employers offer their
product to their employees under certain conditions.
HMO Act of 1973 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 The real advent of employer-based insurance came
statements regarding through Blue Cross, which was started by hospital
employer-based health associations during the Depression.
insurance in the United
States is true?
The Health Maintenance Would have to offer HMO plans along side traditional
Organization (HMO) Act fee-for-service medical plans.
of 1973 gave qualified
HMOs the right to
"mandate" an employer
under certain conditions,
meaning employers:
Which of the following is Providers will face many new service demands and
an anticipated change in consumers will have virtually unfettered access to
the relationships between those services
consumers and providers?
What transition began as a A transition toward new models of health care
result of the March 2010 delivery with corresponding changes system
healthcare reform financing and provider reimbursement.
legislation?
ABN began establishing new requirements for
Which statement is false
managed care plans participating in the Medicare
concerning ABNs?
program.
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CSPR - Certified Specialist Payment Rep (HFMA)
Exam fully solved & updated 2025-2026(latest
version verified for accuracy) | 2024\2025 Latest!!
Save
Terms in this set (125)
Steps used to control Bundled codes
costs of managed care Capitation
include: Payer and Provider to agree on reasonable payment
Inpatient admissions for the purpose of reimbursing
hospitals for each case in a given category w/a
DRG is used to classify
negotiated fixed fee, regardless of the actual costs
incurred
HMO
Conventional
Identify the various types PPO and POS
of private health plan HDHP/SO plans - high-deductible health plans with a
coverage savings option; Private - Include higher patient out-
of-pocket expenditures for treatments that can serve
to reduce utilization/costs.
Health Maintenance Organizations (HMO)
Managed care
Preferred Provider Organizations (PPO)
organizations (MCO) exist
Point of Service (POS) Organizations
primarily in four forms:
Exclusive Provider Organizations (EPO)
https://quizlet.com/1085610024/cspr-certified-specialist-payment-rep-hfma-exam-fully-solved-updated-2025-2026latest-version-verified-for-accuracy-… 1/29
,10/1/25, 12:04 PM CSPR - Certified Specialist Payment Rep (HFMA) Exam fully solved & updated 2025-2026(latest version verified for accuracy) | 2…
Medicare - Government; Beneficiaries enrolled in
such plans, but, participation in these
plans is voluntary.
Identify the various types
Medicaid
of government‐sponsored
Medicaid Managed Care - Medicaid beneficiaries are
health coverage:
required to select and enroll in a managed care plan.
Medicare Managed Care (a.k.a. Medicare Advantage
Plans)
Demographics
Chronic Conditions
Provider payment systems - Provider payment
Identify some key drivers systems that are designed to reward volume rather
of increasing healthcare than quality, outcomes, and prevention
costs Consumer Perceptions
Health Plan pressure
Physician Relationships
Supply Chain
Referrals
PCP
Health Maintenance Patients must use an in-network provider for their
Organizations (HMO) services to be covered.
Reimbursement - majority of services offered are
reimbursed through capitation payments (PMPM)
Part A - provides inpatient/hospital, hospice, and
skilled nursing coverage
Part B - provides outpatient/medical coverage
Medicare is composed of
Part C - an alternative way to receive your Medicare
four parts:
benefits (known as Medicare
Advantage)
Part D - prescription drug coverage
https://quizlet.com/1085610024/cspr-certified-specialist-payment-rep-hfma-exam-fully-solved-updated-2025-2026latest-version-verified-for-accuracy-… 2/29
, 10/1/25, 12:04 PM CSPR - Certified Specialist Payment Rep (HFMA) Exam fully solved & updated 2025-2026(latest version verified for accuracy) | 2…
The HMO Act of 1973 gave federally qualified HMOs
the right to mandate that employers offer their
product to their employees under certain conditions.
HMO Act of 1973 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 The real advent of employer-based insurance came
statements regarding through Blue Cross, which was started by hospital
employer-based health associations during the Depression.
insurance in the United
States is true?
The Health Maintenance Would have to offer HMO plans along side traditional
Organization (HMO) Act fee-for-service medical plans.
of 1973 gave qualified
HMOs the right to
"mandate" an employer
under certain conditions,
meaning employers:
Which of the following is Providers will face many new service demands and
an anticipated change in consumers will have virtually unfettered access to
the relationships between those services
consumers and providers?
What transition began as a A transition toward new models of health care
result of the March 2010 delivery with corresponding changes system
healthcare reform financing and provider reimbursement.
legislation?
ABN began establishing new requirements for
Which statement is false
managed care plans participating in the Medicare
concerning ABNs?
program.
https://quizlet.com/1085610024/cspr-certified-specialist-payment-rep-hfma-exam-fully-solved-updated-2025-2026latest-version-verified-for-accuracy-… 3/29
