CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) 2024-
2025 REAL EXAM AND STUDY GUIDE
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
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.
, CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) 2024-
2025 REAL EXAM AND STUDY GUIDE
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
Identify some key drivers of increasing healthcare costs - Correct 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
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 - 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.
2025 REAL EXAM AND STUDY GUIDE
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
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.
, CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) 2024-
2025 REAL EXAM AND STUDY GUIDE
Medicare Managed Care (a.k.a. Medicare Advantage Plans)
Identify some key drivers of increasing healthcare costs - Correct 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
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 - 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.
