CSPR CERTIFIED SPECIALIST PAYMENT REP
REVIEW FILE 2026 TESTED QUESTIONS
◉ 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
◉ Health Maintenance Organizations (HMO). Answer: Referrals
PCP
Patients must use an in-network provider for their services to be
covered.
REVIEW FILE 2026 TESTED QUESTIONS
◉ 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
◉ Health Maintenance Organizations (HMO). Answer: Referrals
PCP
Patients must use an in-network provider for their services to be
covered.
