HFMA CSPR Exam ACTUAL EXAM
2026/2027 | HFMA Certified Specialist
Patient Accounting | Verified Q&A |
Pass Guaranteed - A+ Graded
Section 1: Revenue Cycle Management for Physician Practices
Q1: A physician practice's A/R days have increased from 32 to 48 over the past three months. Which of
the following is the most likely primary cause?
A. Decreased patient volume
B. Delayed claim submission due to charge capture backlog [CORRECT]
C. Reduction in Medicare fee schedule rates
D. Increased patient co-pays at time of service
Correct Answer: B
Rationale: [CORRECT] A/R days measure the average time between service date and payment receipt.
Delayed charge capture directly extends the billing cycle before claims are even submitted, inflating A/R
days. A – Lower patient volume does not inherently extend payment timelines. C – Fee schedule
changes affect reimbursement amount, not timing. D – Collecting co-pays upfront improves cash flow
and would typically decrease, not increase, A/R days.
Q2: During the patient scheduling process, which activity is most critical to preventing denials for "lack
of authorization" for a scheduled surgery?
A. Verifying the patient’s demographic information against the medical record.
B. Obtaining and documenting the prior authorization number before the date of service. [CORRECT]
C. Checking the patient’s insurance card expiration date.
D. Estimating the patient’s out-of-pocket responsibility.
,Correct Answer: B
Rationale: [CORRECT] Obtaining prior authorization ensures the payer has approved the medical
necessity of the service prior to rendering it, which is a prerequisite for many surgical procedures. A –
While important for clean claims, it does not secure approval for the specific procedure. C – Checking
expiration dates is part of eligibility but does not guarantee procedure authorization. D – Financial
estimation helps with collections but does not prevent medical necessity or authorization denials.
Q3: A practice receives an ERA (Electronic Remittance Advice) showing a claim paid at 80% of the billed
charges, with the patient responsibility listed as 20%. The contract stipulates a fee schedule amount
lower than the billed charges. How should the payment posting team handle the contractual
adjustment?
A. Write off the difference between billed charges and the paid amount as a contractual adjustment.
B. Write off the difference between the billed charges and the contracted fee schedule amount as a
contractual adjustment. [CORRECT]
C. Bill the patient for the full difference between the paid amount and billed charges.
D. Appeal the claim to request 100% of billed charges.
Correct Answer: B
Rationale: [CORRECT] Contractual adjustments are the difference between the practice's billed charges
and the agreed-upon fee schedule amount with the payer. A – This would incorrectly write off the
patient’s responsibility portion if the patient owes coinsurance on the allowed amount. C – Balance
billing the difference between charges and the allowed amount is prohibited in contracted
arrangements. D – Contracted rates are fixed; appealing based on charges is invalid.
Q4: Which metric best measures the efficiency of the billing office in resolving claim rejections?
A. Net Collection Rate.
B. First Pass Resolution Rate. [CORRECT]
C. Days in Accounts Receivable.
D. Cost to Collect.
Correct Answer: B
Rationale: [CORRECT] First Pass Resolution Rate measures the percentage of claims paid on the first
submission without rejections or denials, directly reflecting billing office efficiency and claim cleanliness.
, A – Net collection rate measures the collection effectiveness relative to expected reimbursement. C –
A/R days measures timeliness of payment, not specific rejection handling. D – Cost to collect measures
the expense to run the revenue cycle department.
Q5: A claim is denied with remark code CO-97 (The benefit for this service is included in the
payment/allowance for another service). Which revenue cycle process should be reviewed first?
A. Patient eligibility verification.
B. Charge capture and coding bundling logic. [CORRECT]
C. Referring physician NPI validation.
D. Coordination of benefits.
Correct Answer: B
Rationale: [CORRECT] CO-97 indicates a bundling issue where a service is considered part of a larger
procedure. This points to coding edits (NCCI) or modifier usage (e.g., Modifier 59) being applied or
missed. A – Eligibility issues usually result in CO-4 or CO-27 denials. C – Referring physician issues usually
result in CO-16 or CO-248. D – COB issues typically result in CO-22 or CO-23.
Q6: A new patient presents for an office visit but cannot provide their insurance card. The front desk
decides to see the patient regardless. What is the most significant financial risk to the practice?
A. The claim will be rejected for missing subscriber information.
B. The patient may be a "self-pay" patient who cannot afford the visit.
C. The practice may not be able to verify if the service is covered or requires authorization, leading to
unbillable services. [CORRECT]
D. The medical record will be incomplete.
Correct Answer: C
Rationale: [CORRECT] Without insurance information, the practice cannot verify coverage or
authorization requirements, potentially rendering the service non-covered and financially liable to the
patient or practice. A – While true, the claim rejection is a symptom of the larger issue: inability to verify
coverage. B – Self-pay is manageable if identified; the risk is the unknown status. D – Clinical
documentation is separate from insurance data.
2026/2027 | HFMA Certified Specialist
Patient Accounting | Verified Q&A |
Pass Guaranteed - A+ Graded
Section 1: Revenue Cycle Management for Physician Practices
Q1: A physician practice's A/R days have increased from 32 to 48 over the past three months. Which of
the following is the most likely primary cause?
A. Decreased patient volume
B. Delayed claim submission due to charge capture backlog [CORRECT]
C. Reduction in Medicare fee schedule rates
D. Increased patient co-pays at time of service
Correct Answer: B
Rationale: [CORRECT] A/R days measure the average time between service date and payment receipt.
Delayed charge capture directly extends the billing cycle before claims are even submitted, inflating A/R
days. A – Lower patient volume does not inherently extend payment timelines. C – Fee schedule
changes affect reimbursement amount, not timing. D – Collecting co-pays upfront improves cash flow
and would typically decrease, not increase, A/R days.
Q2: During the patient scheduling process, which activity is most critical to preventing denials for "lack
of authorization" for a scheduled surgery?
A. Verifying the patient’s demographic information against the medical record.
B. Obtaining and documenting the prior authorization number before the date of service. [CORRECT]
C. Checking the patient’s insurance card expiration date.
D. Estimating the patient’s out-of-pocket responsibility.
,Correct Answer: B
Rationale: [CORRECT] Obtaining prior authorization ensures the payer has approved the medical
necessity of the service prior to rendering it, which is a prerequisite for many surgical procedures. A –
While important for clean claims, it does not secure approval for the specific procedure. C – Checking
expiration dates is part of eligibility but does not guarantee procedure authorization. D – Financial
estimation helps with collections but does not prevent medical necessity or authorization denials.
Q3: A practice receives an ERA (Electronic Remittance Advice) showing a claim paid at 80% of the billed
charges, with the patient responsibility listed as 20%. The contract stipulates a fee schedule amount
lower than the billed charges. How should the payment posting team handle the contractual
adjustment?
A. Write off the difference between billed charges and the paid amount as a contractual adjustment.
B. Write off the difference between the billed charges and the contracted fee schedule amount as a
contractual adjustment. [CORRECT]
C. Bill the patient for the full difference between the paid amount and billed charges.
D. Appeal the claim to request 100% of billed charges.
Correct Answer: B
Rationale: [CORRECT] Contractual adjustments are the difference between the practice's billed charges
and the agreed-upon fee schedule amount with the payer. A – This would incorrectly write off the
patient’s responsibility portion if the patient owes coinsurance on the allowed amount. C – Balance
billing the difference between charges and the allowed amount is prohibited in contracted
arrangements. D – Contracted rates are fixed; appealing based on charges is invalid.
Q4: Which metric best measures the efficiency of the billing office in resolving claim rejections?
A. Net Collection Rate.
B. First Pass Resolution Rate. [CORRECT]
C. Days in Accounts Receivable.
D. Cost to Collect.
Correct Answer: B
Rationale: [CORRECT] First Pass Resolution Rate measures the percentage of claims paid on the first
submission without rejections or denials, directly reflecting billing office efficiency and claim cleanliness.
, A – Net collection rate measures the collection effectiveness relative to expected reimbursement. C –
A/R days measures timeliness of payment, not specific rejection handling. D – Cost to collect measures
the expense to run the revenue cycle department.
Q5: A claim is denied with remark code CO-97 (The benefit for this service is included in the
payment/allowance for another service). Which revenue cycle process should be reviewed first?
A. Patient eligibility verification.
B. Charge capture and coding bundling logic. [CORRECT]
C. Referring physician NPI validation.
D. Coordination of benefits.
Correct Answer: B
Rationale: [CORRECT] CO-97 indicates a bundling issue where a service is considered part of a larger
procedure. This points to coding edits (NCCI) or modifier usage (e.g., Modifier 59) being applied or
missed. A – Eligibility issues usually result in CO-4 or CO-27 denials. C – Referring physician issues usually
result in CO-16 or CO-248. D – COB issues typically result in CO-22 or CO-23.
Q6: A new patient presents for an office visit but cannot provide their insurance card. The front desk
decides to see the patient regardless. What is the most significant financial risk to the practice?
A. The claim will be rejected for missing subscriber information.
B. The patient may be a "self-pay" patient who cannot afford the visit.
C. The practice may not be able to verify if the service is covered or requires authorization, leading to
unbillable services. [CORRECT]
D. The medical record will be incomplete.
Correct Answer: C
Rationale: [CORRECT] Without insurance information, the practice cannot verify coverage or
authorization requirements, potentially rendering the service non-covered and financially liable to the
patient or practice. A – While true, the claim rejection is a symptom of the larger issue: inability to verify
coverage. B – Self-pay is manageable if identified; the risk is the unknown status. D – Clinical
documentation is separate from insurance data.
