CSPR - Cer fied Specialist Payment Rep (HFMA) With
125 Ques ons and answers Newest RATED A+
2025/2026 NEW!!
Steps used to control costs of managed care include: - Ans Bundled codes
Capita on
Payer and Provider to agree on reasonable payment
DRG is used to classify - Ans Inpa ent admissions for the purpose of reimbursing hospitals for
each case in a given category w/a nego ated fixed fee, regardless of the actual costs incurred
Iden fy the various types of private health plan coverage - Ans HMO
Conven onal
PPO and POS
HDHP/SO plans - high-deduc ble health plans with a savings op on; Private - Include higher
pa ent out-of-pocket expenditures for treatments that can serve to reduce u liza on/costs.
Managed care organiza ons (MCO) exist primarily in four forms: - Ans Health Maintenance
Organiza ons (HMO)
Preferred Provider Organiza ons (PPO)
Point of Service (POS) Organiza ons
Exclusive Provider Organiza ons (EPO)
Iden fy the various types of government-sponsored health coverage: - Ans Medicare -
Government; Beneficiaries enrolled in such plans, but, par cipa on 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)
Iden fy some key drivers of increasing healthcare costs - Ans Demographics
Chronic Condi ons
Provider payment systems - Provider payment systems that are designed to reward volume
rather than quality, outcomes, and preven on
Consumer Percep ons
Health Plan pressure
Physician Rela onships
Supply Chain
Health Maintenance Organiza ons (HMO) - Ans Referrals
PCP
Pa ents must use an in-network provider for their services to be covered.
Reimbursement - majority of services offered are reimbursed through capita on payments
(PMPM)
Medicare is composed of four parts: - Ans Part A - provides inpa ent/hospital, hospice, and
skilled nursing coverage
Part B - provides outpa ent/medical coverage
Part C - an alterna ve way to receive your Medicare benefits (known as Medicare
Advantage)
Part D - prescrip on drug coverage
, HMO Act of 1973 - Ans The HMO Act of 1973 gave federally qualified HMOs the right to
mandate that employers offer their product to their employees under certain condi ons.
Manda ng 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? - Ans The real advent of employer-based insurance came through Blue Cross,
which was started by hospital associa ons during the Depression.
The Health Maintenance Organiza on (HMO) Act of 1973 gave qualified HMOs the right to
"mandate" an employer under certain condi ons, meaning employers: - Ans Would have to
offer HMO plans along side tradi onal fee-for-service medical plans.
Which of the following is an an cipated change in the rela onships between consumers and
providers? - Ans Providers will face many new service demands and consumers will have
virtually unfe?ered access to those services
What transi on began as a result of the March 2010 healthcare reform legisla on? - Ans A
transi on toward new models of health care delivery with corresponding changes system
financing and provider reimbursement.
Which statement is false concerning ABNs? - Ans ABN began establishing new requirements
for managed care plans par cipa ng in the Medicare program.
Which Statement is TRUE concerning ABNs? - Ans -ABNs are not required for services that are
never covered by Medicare.
-An ABN form no fies the pa ent 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 implica ons for the physician, they also
serve an important fraud and abuse compliance func on.
125 Ques ons and answers Newest RATED A+
2025/2026 NEW!!
Steps used to control costs of managed care include: - Ans Bundled codes
Capita on
Payer and Provider to agree on reasonable payment
DRG is used to classify - Ans Inpa ent admissions for the purpose of reimbursing hospitals for
each case in a given category w/a nego ated fixed fee, regardless of the actual costs incurred
Iden fy the various types of private health plan coverage - Ans HMO
Conven onal
PPO and POS
HDHP/SO plans - high-deduc ble health plans with a savings op on; Private - Include higher
pa ent out-of-pocket expenditures for treatments that can serve to reduce u liza on/costs.
Managed care organiza ons (MCO) exist primarily in four forms: - Ans Health Maintenance
Organiza ons (HMO)
Preferred Provider Organiza ons (PPO)
Point of Service (POS) Organiza ons
Exclusive Provider Organiza ons (EPO)
Iden fy the various types of government-sponsored health coverage: - Ans Medicare -
Government; Beneficiaries enrolled in such plans, but, par cipa on 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)
Iden fy some key drivers of increasing healthcare costs - Ans Demographics
Chronic Condi ons
Provider payment systems - Provider payment systems that are designed to reward volume
rather than quality, outcomes, and preven on
Consumer Percep ons
Health Plan pressure
Physician Rela onships
Supply Chain
Health Maintenance Organiza ons (HMO) - Ans Referrals
PCP
Pa ents must use an in-network provider for their services to be covered.
Reimbursement - majority of services offered are reimbursed through capita on payments
(PMPM)
Medicare is composed of four parts: - Ans Part A - provides inpa ent/hospital, hospice, and
skilled nursing coverage
Part B - provides outpa ent/medical coverage
Part C - an alterna ve way to receive your Medicare benefits (known as Medicare
Advantage)
Part D - prescrip on drug coverage
, HMO Act of 1973 - Ans The HMO Act of 1973 gave federally qualified HMOs the right to
mandate that employers offer their product to their employees under certain condi ons.
Manda ng 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? - Ans The real advent of employer-based insurance came through Blue Cross,
which was started by hospital associa ons during the Depression.
The Health Maintenance Organiza on (HMO) Act of 1973 gave qualified HMOs the right to
"mandate" an employer under certain condi ons, meaning employers: - Ans Would have to
offer HMO plans along side tradi onal fee-for-service medical plans.
Which of the following is an an cipated change in the rela onships between consumers and
providers? - Ans Providers will face many new service demands and consumers will have
virtually unfe?ered access to those services
What transi on began as a result of the March 2010 healthcare reform legisla on? - Ans A
transi on toward new models of health care delivery with corresponding changes system
financing and provider reimbursement.
Which statement is false concerning ABNs? - Ans ABN began establishing new requirements
for managed care plans par cipa ng in the Medicare program.
Which Statement is TRUE concerning ABNs? - Ans -ABNs are not required for services that are
never covered by Medicare.
-An ABN form no fies the pa ent 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 implica ons for the physician, they also
serve an important fraud and abuse compliance func on.
