1/23/26, 12:36 PM CSPR - Certified Specialist Payment Rep (HFMA) Exam (Latest 2026/2027 Update) Flashcards | Quizlet
CSPR - Certified Specialist Payment Rep (HFMA) Exam
(Latest 2026/2027 Update)
Save
Terms in this set (125)
Steps used to control costs of managed Bundled codes
care include: Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify 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
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,1/23/26, 12:36 PM CSPR - Certified Specialist Payment Rep (HFMA) Exam (Latest 2026/2027 Update) Flashcards | Quizlet
Identify the various types of private HMO
health plan coverage 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 Health Maintenance Organizations (HMO)
primarily in four forms: Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Identify the various types of government‐ Medicare - Government; Beneficiaries enrolled in such
sponsored health coverage: 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)
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,1/23/26, 12:36 PM CSPR - Certified Specialist Payment Rep (HFMA) Exam (Latest 2026/2027 Update) Flashcards | Quizlet
Identify some key drivers of increasing Demographics
healthcare costs 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 Referrals
(HMO) 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)
https://quizlet.com/1134412750/cspr-certified-specialist-payment-rep-hfma-exam-latest-20262027-update-flash-cards/ 3/35
, 1/23/26, 12:36 PM CSPR - Certified Specialist Payment Rep (HFMA) Exam (Latest 2026/2027 Update) Flashcards | Quizlet
Medicare is composed of four parts: 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 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 The real advent of employer-based insurance came
regarding employer-based health through Blue Cross, which was started by hospital
insurance in the United States is true? associations during the Depression.
https://quizlet.com/1134412750/cspr-certified-specialist-payment-rep-hfma-exam-latest-20262027-update-flash-cards/ 4/35
CSPR - Certified Specialist Payment Rep (HFMA) Exam
(Latest 2026/2027 Update)
Save
Terms in this set (125)
Steps used to control costs of managed Bundled codes
care include: Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify 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
https://quizlet.com/1134412750/cspr-certified-specialist-payment-rep-hfma-exam-latest-20262027-update-flash-cards/ 1/35
,1/23/26, 12:36 PM CSPR - Certified Specialist Payment Rep (HFMA) Exam (Latest 2026/2027 Update) Flashcards | Quizlet
Identify the various types of private HMO
health plan coverage 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 Health Maintenance Organizations (HMO)
primarily in four forms: Preferred Provider Organizations (PPO)
Point of Service (POS) Organizations
Exclusive Provider Organizations (EPO)
Identify the various types of government‐ Medicare - Government; Beneficiaries enrolled in such
sponsored health coverage: 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)
https://quizlet.com/1134412750/cspr-certified-specialist-payment-rep-hfma-exam-latest-20262027-update-flash-cards/ 2/35
,1/23/26, 12:36 PM CSPR - Certified Specialist Payment Rep (HFMA) Exam (Latest 2026/2027 Update) Flashcards | Quizlet
Identify some key drivers of increasing Demographics
healthcare costs 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 Referrals
(HMO) 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)
https://quizlet.com/1134412750/cspr-certified-specialist-payment-rep-hfma-exam-latest-20262027-update-flash-cards/ 3/35
, 1/23/26, 12:36 PM CSPR - Certified Specialist Payment Rep (HFMA) Exam (Latest 2026/2027 Update) Flashcards | Quizlet
Medicare is composed of four parts: 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 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 The real advent of employer-based insurance came
regarding employer-based health through Blue Cross, which was started by hospital
insurance in the United States is true? associations during the Depression.
https://quizlet.com/1134412750/cspr-certified-specialist-payment-rep-hfma-exam-latest-20262027-update-flash-cards/ 4/35
