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 |
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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 |
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 |
