CSPR - Certified Specialist Payment Rep
(HFMA) questions and answers 2025\2026
A+ Grade
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.
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
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.
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.
Which Statement is TRUE concerning ABNs?
- correct 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?
- correct answer The pay for medical assistance for certain individuals and low-income families
(HFMA) questions and answers 2025\2026
A+ Grade
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.
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
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.
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.
Which Statement is TRUE concerning ABNs?
- correct 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?
- correct answer The pay for medical assistance for certain individuals and low-income families
