Certified Specialist Payment Rep (HFMA) Exam
Questions and Answers Latest Update 2025
Steps used to control costs of managed care include:
Correct Answer: Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify
Correct 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
Correct Answer: HMO
Conventional
PPO and POS
1
,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:
Correct 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:
Correct 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
Correct Answer: Demographics
Chronic Conditions
2
,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)
Correct 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:
Correct 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
3
, Correct 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?
Correct 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:
Correct 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?
Correct 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?
4
Questions and Answers Latest Update 2025
Steps used to control costs of managed care include:
Correct Answer: Bundled codes
Capitation
Payer and Provider to agree on reasonable payment
DRG is used to classify
Correct 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
Correct Answer: HMO
Conventional
PPO and POS
1
,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:
Correct 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:
Correct 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
Correct Answer: Demographics
Chronic Conditions
2
,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)
Correct 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:
Correct 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
3
, Correct 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?
Correct 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:
Correct 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?
Correct 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?
4
