CSPR CERTIFIED SPECIALIST PAYMENT REP
STUDY GUIDE 2026 FULL QUESTIONS AND
CORRECT ANSWERS
• Managed care organizations (MCO) exist primarily in four forms:.
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:. 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. 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). 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:. 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. 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?. 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:. 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?. 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?. Answer: A transition toward new models of
health care delivery with corresponding changes system financing
and provider reimbursement.
, • Which statement is false concerning ABNs?. Answer: ABN began
establishing new requirements for managed care plans participating
in the Medicare program.
• Which Statement is TRUE concerning ABNs?. 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?. Answer: The pay for
medical assistance for certain individuals and low‐income families
• Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined
as:. Answer: Total Medical Expenses divided by Total Premiums
• Provider service organizations (PSOs) function like health
maintenance organizations (HMOs) in all of the following ways,
EXCEPT:. Answer: Ties to the healthcare delivery industry rather
than the insurance industry
STUDY GUIDE 2026 FULL QUESTIONS AND
CORRECT ANSWERS
• Managed care organizations (MCO) exist primarily in four forms:.
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:. 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. 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). 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:. 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. 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?. 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:. 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?. 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?. Answer: A transition toward new models of
health care delivery with corresponding changes system financing
and provider reimbursement.
, • Which statement is false concerning ABNs?. Answer: ABN began
establishing new requirements for managed care plans participating
in the Medicare program.
• Which Statement is TRUE concerning ABNs?. 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?. Answer: The pay for
medical assistance for certain individuals and low‐income families
• Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined
as:. Answer: Total Medical Expenses divided by Total Premiums
• Provider service organizations (PSOs) function like health
maintenance organizations (HMOs) in all of the following ways,
EXCEPT:. Answer: Ties to the healthcare delivery industry rather
than the insurance industry
