CSPR - Certified Specialist Payment Rep
(HFMA) Exam (Latest 2026/2027| Actual
Complete Questions and Verified Answers|
Graded A+
Steps used to control costs of managed care include the following: -
ANSWER✔✔-One step ‐ For the payer and provider to agree on
reasonable payment for each service. In general, this payment
arrangement results in payment rates that are beneath the rates that
a provider would charge to an uninsured individual.
-A next step ‐ Might include combining services that are typically
provided in conjunction with one another and bundling the associated
charges and determining an appropriate charge for that set of
services or type of care.
-Further efforts ‐ Might include making advance payment to providers
for all services needed to care for a member. This form of payment is
referred to as capitation, or per capita payment.
The basic reimbursement methodologies used for hospital services
include the following: - ANSWER✔✔-Percent‐of‐charge payments ‐ A
negotiated percentage off of billed charges
and can be applied to any or all of the services that the hospital
provides.
-Per diem payments ‐ Refers to a fixed amount per patient per
inpatient day.
-Case rate payments ‐ Represent a fixed price for specified care by
paying an agreed‐upon rate for a specific healthcare service.
,-Carve‐outs - Sometimes refer to specific benefits or services that are
administered separately from the rest of the managed care plan and
that may be managed by other third parties.
Professional services reimbursement methodologies include the
following: - ANSWER✔✔-Discounts based negotiated fee schedules
-Payment based on Resource Based Relative Value System (RBRVS)
-Capitation
-Case rates
The four value‐based payment models include the following -
ANSWER✔✔-Bundled payment
-RiskSharing
-Patient‐Centered Medical Home/Guided Care
-Pay for Performance
Healthcare financial leaders should focus on initiatives that will help
them increase their organization's revenue/profit/ margins, such as: -
ANSWER✔✔-Payment policing and standardization of contract
requirements.
-Contract performance modeling.
-Shift in volume and cost risk to hospitals.
-Health plan consolidation.
The trends which have arisen from the focus on reducing healthcare
costs while improving quality and outcomes include the following: -
ANSWER✔✔-Shift from broad‐based toward more focused efforts
,-Reduction of administrative costs
-Greater physician involvement
-Greater patient engagement
-Focus of case management on care and resources
-Increased use of team‐based health care
The three technique application methods used for utilization
management include the following: - ANSWER✔✔-Prospective UM
Techniques - UM reviews the need for inpatient care or other care
before admission. The health plan
determines, at this point, whether it will pay for the service
-Concurrent UM Techniques - Authorization required during a patient's
inpatient admission
-Retrospective UM Techniques - Authorization reviews to determine
medical necessity of a service, treatment or
procedure
Catastrophic Case Management - ANSWER✔✔used to manage
diseases associated with very high costs of care.
PCMH model - ANSWER✔✔a term used to describe a model of care in
which primary care services are delivered to families in an accessible,
continuous, comprehensive, and integrated fashion.
The specific roles and responsibility of each level within the small
physician practice managed care infrastructure included the following:
- ANSWER✔✔-Practice Manager ‐ Oversee all operational aspects of
, the practice, including managed care contracting.
-Physician Leader(s) ‐ Provide input to the practice manager regarding
expected/target reimbursement rates and help identify any specific
aspects of the contract that may be difficult to administer.
-Registration Staff ‐ Assist with eligibility verification and accurate
entry of patient insurance information into the practice management
or billing system.
-Clinical Staff ‐ Must be familiar with payer requirements for
appropriate documentation of medical necessity and protocols for pre‐
authorizations.
-Billing Staff ‐ Responsible for submitting claims to the appropriate
payers and managing payments received from payers and patients.
Electronic Data Interchange (EDI) - ANSWER✔✔the exchange of
computerized data in a standardized format allows both healthcare
providers and payers to exchange common information required to
improve the quality of care while measurably reducing the cost of that
care.
Information required for claims processing includes the following: -
ANSWER✔✔-Patient and/or enrollee identification, DOB, and sex
-Assigned group
-Provider or referring provider identification, as appropriate
-Dateofservice
-Type of service
-Type of diagnosis/major diagnostic category -Procedure code(s): CPT
and HCPCS codes
-COB information
(HFMA) Exam (Latest 2026/2027| Actual
Complete Questions and Verified Answers|
Graded A+
Steps used to control costs of managed care include the following: -
ANSWER✔✔-One step ‐ For the payer and provider to agree on
reasonable payment for each service. In general, this payment
arrangement results in payment rates that are beneath the rates that
a provider would charge to an uninsured individual.
-A next step ‐ Might include combining services that are typically
provided in conjunction with one another and bundling the associated
charges and determining an appropriate charge for that set of
services or type of care.
-Further efforts ‐ Might include making advance payment to providers
for all services needed to care for a member. This form of payment is
referred to as capitation, or per capita payment.
The basic reimbursement methodologies used for hospital services
include the following: - ANSWER✔✔-Percent‐of‐charge payments ‐ A
negotiated percentage off of billed charges
and can be applied to any or all of the services that the hospital
provides.
-Per diem payments ‐ Refers to a fixed amount per patient per
inpatient day.
-Case rate payments ‐ Represent a fixed price for specified care by
paying an agreed‐upon rate for a specific healthcare service.
,-Carve‐outs - Sometimes refer to specific benefits or services that are
administered separately from the rest of the managed care plan and
that may be managed by other third parties.
Professional services reimbursement methodologies include the
following: - ANSWER✔✔-Discounts based negotiated fee schedules
-Payment based on Resource Based Relative Value System (RBRVS)
-Capitation
-Case rates
The four value‐based payment models include the following -
ANSWER✔✔-Bundled payment
-RiskSharing
-Patient‐Centered Medical Home/Guided Care
-Pay for Performance
Healthcare financial leaders should focus on initiatives that will help
them increase their organization's revenue/profit/ margins, such as: -
ANSWER✔✔-Payment policing and standardization of contract
requirements.
-Contract performance modeling.
-Shift in volume and cost risk to hospitals.
-Health plan consolidation.
The trends which have arisen from the focus on reducing healthcare
costs while improving quality and outcomes include the following: -
ANSWER✔✔-Shift from broad‐based toward more focused efforts
,-Reduction of administrative costs
-Greater physician involvement
-Greater patient engagement
-Focus of case management on care and resources
-Increased use of team‐based health care
The three technique application methods used for utilization
management include the following: - ANSWER✔✔-Prospective UM
Techniques - UM reviews the need for inpatient care or other care
before admission. The health plan
determines, at this point, whether it will pay for the service
-Concurrent UM Techniques - Authorization required during a patient's
inpatient admission
-Retrospective UM Techniques - Authorization reviews to determine
medical necessity of a service, treatment or
procedure
Catastrophic Case Management - ANSWER✔✔used to manage
diseases associated with very high costs of care.
PCMH model - ANSWER✔✔a term used to describe a model of care in
which primary care services are delivered to families in an accessible,
continuous, comprehensive, and integrated fashion.
The specific roles and responsibility of each level within the small
physician practice managed care infrastructure included the following:
- ANSWER✔✔-Practice Manager ‐ Oversee all operational aspects of
, the practice, including managed care contracting.
-Physician Leader(s) ‐ Provide input to the practice manager regarding
expected/target reimbursement rates and help identify any specific
aspects of the contract that may be difficult to administer.
-Registration Staff ‐ Assist with eligibility verification and accurate
entry of patient insurance information into the practice management
or billing system.
-Clinical Staff ‐ Must be familiar with payer requirements for
appropriate documentation of medical necessity and protocols for pre‐
authorizations.
-Billing Staff ‐ Responsible for submitting claims to the appropriate
payers and managing payments received from payers and patients.
Electronic Data Interchange (EDI) - ANSWER✔✔the exchange of
computerized data in a standardized format allows both healthcare
providers and payers to exchange common information required to
improve the quality of care while measurably reducing the cost of that
care.
Information required for claims processing includes the following: -
ANSWER✔✔-Patient and/or enrollee identification, DOB, and sex
-Assigned group
-Provider or referring provider identification, as appropriate
-Dateofservice
-Type of service
-Type of diagnosis/major diagnostic category -Procedure code(s): CPT
and HCPCS codes
-COB information
