Certified Specialist Payment & Reimbursement (CSPR)

Get recognized as a valued contributor to your organization’s financial performance when you earn HFMA’s Certified Specialist Payment & Reimbursement (CSPR) certification.

Those who earn this certification have demonstrated specialist-level knowledge of the managed care environment, payment rates, benefit coordination, reimbursement models, cost-control incentives, legislative changes, and more.

Available online, 24/7, this certification, online program, certification maintenance, and digital badging related costs are all included in HFMA membership.

Estimated course completion time: 10-13 hours.

Course Outline:

1. CSPR Course Introduction

• Getting Started

2. CSPR Course 1 – Overview of Managed Care

• Introduction
• Part 1: Introduction and Evolution of Managed Care
• Part 2: Managed Care Today
• Part 3: Public Policy and Market Performance Issues
• Part 4: The Future Direction of Managed Care
• Conclusion

3. CSPR Course 2 – Essentials of Medicare and Medicaid Managed Care

• Introduction
• Part 1: Brief History of Medicare
• Part 2: Medicare—Reimbursement, Law Changes, Demonstration Projects
• Part 3: Medicare—ABNs, MSPQs, MOONs, Rights and Responsibilities of Enrollees, and Part D
• Part 4: Managed Medicaid Successes and Failures
• Conclusion

4. CSPR Course 3 – Healthcare Delivery Systems

• Introduction
• Part 1: Managed Care Models and the Relationship Between Providers and Payers
• Part 2: Provider and Payer Financial Relationship
• Part 3: Tiered Networks and Pricing
• Conclusion

5. CSPR Course 4 – Managed Care Reimbursement Methodologies

• Introduction
• Part 1: Introduction to Financial Management
• Part 2 : Basic Reimbursement Methodologies—Hospital Services
• Part 3: Advanced Reimbursement Methodologies—Hospital Services
• Part 4 : Basic Reimbursement Methodologies—Professional Services
• Conclusion

6. CSPR Course 5 – Managed Care: Incentives, Emerging Trends, and Risks

• Introduction
• Part 1: Challenges in Aligning Incentives
• Part 2: Emerging Payment Trends—Healthcare Financial Management Under Healthcare Reform
• Part 3: Emerging Payment Trends—Bolstering Your Revenue Stream
• Part 4: Risk Management and Funding Mechanisms
• Conclusion

7. CSPR Course 6 – Managed Care: Trends in Case and Utilization Management

• Introduction
• Part 1: Case (Care) Management and Clinical Integration Components
• Part 2: Utilization Management
• Part 3: Management of Patient Care
• Part 4: Demand Management and Physician-Driven Medical Management
• Conclusion

8. CSPR Course 7 – Provider and Payer Infrastructure and Process

• Introduction
• Part 1: Provider and Payor Managed Care Infrastructure
• Part 2: Claims Administration Process – Provider and Payer
• Conclusion

9. CSPR Course 8 – Trends in Healthcare Policy

• Introduction
• Part 1: The National Healthcare Debate
• Part 2: Effect of Consumer Awareness
• CDHPs
• HSAs
• Part 3: Outcomes-Based Reimbursement, Pay-for-Performance Programs, and Coordination of Care
• Conclusion

10. CSPR Course 9 – Healthcare Industry Regulation and Accreditation

• Introduction
• Part 1: Accreditation Organizations
• Part 2: HMO Solvency and ERISA
• Part 3 : Prompt Payment, COBRA, and EMTALA
• Part 4: URAC
• Part 5: HIPAA, National Practice Database, QISMC, and EHR Standards
• Part 6: NCQA and PPACA
• Conclusion

11. CSPR Course 10 – Contracting and Negotiating

• Introduction
• Part 1: How to Evaluate a Contract
• Part 2: General Issues in Contracting—Provider/Payer
• Part 3: Common Contract Clauses and Key Contract Provisions
• Part 4: Direct Contracting, Third-Party Contracting, Silent PPOs and Non-Directed PPOs
• Conclusion

12. Certified Specialist Payment & Reimbursement (CSPR) – Assessment

• CSPR Assessment

Learning Objectives:

• Identify key factors that influenced the development of managed care
• Explain coordination of benefits, managed Medicare organizations, and TRICARE
• Describe the role of Medicare and Medicaid Managed Care
• Identify the clinical integration components of case management
• Describe basic hospital service reimbursement methodologies and cost control incentives
• Describe the impact of the ACA on reimbursement, and list emerging payment trends under healthcare reform
• List key case and utilization (care) management and clinical integration components
• Identify major trends in healthcare policy, including consumerism, outcomes-based reimbursement, and other elements of reform

CPE Information:

CPE Award Amount: 13.0

Program Level: Intermediate

Program Prerequisite: Knowledge of health care payment and reimbursement models, managed care environment, payment rates, benefit coordination and legislative changes.

Recommended Experience: 1-2 years experience in payment, reimbursement or managed care setting.

Advanced Preparation: None

Instructional Method: Self-Study

Delivery Method: QAS Self-Study

Field of Study & Topic in hours: 13.0 Specialized Knowledge

Content last revised: October 2021

CPE Sponsor– Healthcare Financial Management Association is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: www.nasbaregistry.org.

For more information regarding refund policies, as well as any program concerns, please contact our offices at 800.252.4362 or, [email protected].

ACE College Credit for Students:

A Student member of HFMA? The American Council on Education’s College Credit Recommendation Service (ACE CREDIT®) has evaluated and recommended college credit for the Certified Specialist Payment & Reimbursement (CSPR).

Earn college credit. Take one less class! Student members of HFMA can earn 1 college credit outside the classroom when successfully completing the Certified Specialist Payment & Reimbursement (CSPR) program.

Level: Lower-Division Baccalaureate

Credits: 1

Subject: Health insurance and reimbursement

Healthcare Financial Management Association (HFMA) (acenet.edu) – ACE National Guide

General Program Information | Certification Maintenance Information