CSPR - Certified Specialist
Payment Rep (HFMA) ACTUAL
EXAM 2026 TEST
COMPREHENSIVE QUESTIONS
AND VERIFIED ANSWERS
(DETAILED & ELABORATED)
100% SOLVED
Steps used to control costs of managed care include: - 🧠 ANSWER
✔✔Bundled codes
,Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - 🧠 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 - 🧠 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: - 🧠
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
COPYRIGHT©PROFFKERRYMARTIN 2025/2026. YEAR PUBLISHED 2026. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE.
PRIVACY STATEMENT. ALL RIGHTS RESERVED
, 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
Payment Rep (HFMA) ACTUAL
EXAM 2026 TEST
COMPREHENSIVE QUESTIONS
AND VERIFIED ANSWERS
(DETAILED & ELABORATED)
100% SOLVED
Steps used to control costs of managed care include: - 🧠 ANSWER
✔✔Bundled codes
,Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify - 🧠 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 - 🧠 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: - 🧠
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
COPYRIGHT©PROFFKERRYMARTIN 2025/2026. YEAR PUBLISHED 2026. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE.
PRIVACY STATEMENT. ALL RIGHTS RESERVED
, 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
