1|Page
CSPR - Certified Specialist Payment Rep
(HFMA) 2025 | Certified Exam Q&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.
,2|Page
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
,3|Page
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.
, 4|Page
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.
CSPR - Certified Specialist Payment Rep
(HFMA) 2025 | Certified Exam Q&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.
,2|Page
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
,3|Page
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.
, 4|Page
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.
