Deck 4: Network Management

Question 1

The Avignon Company discontinued its contract with a traditional indemnity insurer and contracted exclusively with the Minaret Health Plan to provide the sole healthcare plan to Avignon's employees. By agreeing to an exclusive contract with Minaret, Avignon has entered into a type of healthcare contract known as

A) a carrier guarantee arrangement
B) open access
C) total replacement coverage
D) selective contract coverage

Answer 1

C

Question 2

The National Committee for Quality Assurance (NCQA) has integrated accreditation with Health Employer Data and Information Set (HEDIS) measures into a program called Accreditation '99. One statement that can correctly be made about these accreditation standards is that

A) Health plans are required by law to report HEDIS results to NCQA
B) HEDIS restricts its reporting criteria to a narrow group of quantitative performance measures, while NCQA includes a broad range of qualitative performance measures
C) Private employer groups purchasing health care coverage increasingly require both NCQA accreditation and HEDIS reporting
D) HEDIS includes measures of a health plan's effectiveness of care rather than its cost of care

Answer 2

C

Question 3

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO. The network strategy that Gardenia is using to establish its range of healthcare plans is known as the

A) network-within-a-network approach
B) gatekeeper approach
C) tiered network approach
D) preferred tier approach

Answer 3

A

Question 4

After HIPAA was enacted, Congress amended the law to include the Mental Health Parity Act (MHPA) of 1996, a federal requirement relating to mental health benefits. One true statement about the MHPA is that it

A) requires all health plans to provide coverage for mental health services
B) requires health plans to carve out mental/behavioral healthcare from other services provided by the plans
C) allows health plans to require patients receiving mental health services to pay higher copayments than patients seeking treatment for physical illnesses
D) prohibits health plans that offer mental health benefits from applying more restrictive limits on coverage for mental illness than on coverage for physical illness

Question 5

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO. The following statement(s) can correctly be made about Gardenia's establishment of the PPO and the staff model HMO in its new market: 1. When establishing its PPO network, Gardenia most likely initiated outcomes measurement tools and developed collaborative process improvement relationships with providers. 2. To avoid high overhead expenses in the early stages of market evelopment, Gardenia's HMO most likely contracted with specialists and ancillary providers until the plan's membership grew to a sufficient level to justify employing these specialists.

A) Both 1 and 2
B) Neither 1 nor 2
C) 1 Only
D) 2 Only

Question 6

The sizes of the businesses in a market affect the types of health programs that are likely to be purchased. Compared to smaller employers (those with fewer than 100 employees), larger employers (those with more than 1,000 employees) are

A) more likely to contract with indemnity health plans
B) more likely to offer their employees a choice in health plans
C) less likely to contract with health plans
D) less likely to require a wide variety of benefits

Question 7

Lakesha Frazier, a member of a health plan in a rural area, had been experiencing heart palpitations and shortness of breath. Ms. Frazier's primary care provider (PCP) referred her to a local hospital for an electrocardiogram. The results of the electrocardiogram were transmitted for diagnosis via high-speed data transmission to a heart specialist in a city 500 miles away. This information indicates that the results of Ms. Frazier's electrocardiogram were transmitted using a communications system known as

A) Anarrow network
B) An integrated healthcare delivery system
C) Telemedicine
D) Customized networking

Question 8

Some jurisdictions have enacted corporate practice of medicine laws. One effect that corporate practice of medicine laws have had on HMO provider networks is that these laws typically

A) require incorporated HMOs to practice medicine through licensed employees
B) require HMOs to form exclusive contracts with physician groups who agree to dedicate all or most of their practices to HMO patients in return for a set payment or revenue-sharing
C) restrict the ability of staff model HMOs to hire physicians directly, unless the physicians own the HMO
D) encourage incorporated HMOs to obtain profits from their provisions of physician professional services

Question 9

In developing a provider network in an large city with a high concentration of young families, the Gypsum Health Plan has set goals focused on the needs of that particular market. The following statements are about this situation. Three of the statements are true, and one of the statements is false. Select the answer choice that contains the FALSE statement.

A) Gypsum should attempt to recruit providers who offer extended office hours.
B) Gypsum can use the cost-effectiveness of its own existing networks as a benchmark for its cost-savings goals in this market.
C) Gypsum will most likely attempt to contract with HMOs.
D) Gypsum most likely should set lower cost-savings goals in this market than it would in a rural market with few young families.

Question 10

The National Association of Insurance Commissioners (NAIC) Managed Care Plan Network Adequacy Model Act defines specific adequacy and accessibility standards that health plans must meet. In addition, the Model Act requires health plans to

A) Hold plan members responsible for unreimbursed charges or unpaid claims
B) Allow providers to develop their own standards of care
C) Adhere to specified disclosure requirements related to provider contract termination
D) File written access plans and sample contracts with the Centers for Medicaid and Medicare Services (CMS)

Question 11

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen. In most states, a health plan can be held responsible for a provider's negligent malpractice. This legal concept is known as (vicarious liability / risk sharing). One step that health plans can take to reduce their exposure to malpractice lawsuits is to state in health plan-provider agreements, marketing collateral, and membership literature that the providers are (employees of the health plan / independent contractors).

A) Vicarious liability / employees of the health plan
B) Vicarious liability / independent contractors
C) Risk sharing / employees of the health plan
D) Risk sharing / independent contractors

Question 12

Although a health plan is allowed to delegate many activities to outside sources, the National Committee for Quality Assurance (NCQA) has determined that some activities are not delegable. These activities include

A) evaluation of new medical technologies
B) overseeing delegated medical records activities
C) developing written statements of members' rights and responsibilities
D) all of the above

Question 13

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO. One statement that can correctly be made about Gardenia's two-level POS product is that

A) members who self-refer without first seeing their PCPs will receive no benefits
B) both Gardenia and the PCPs stand to benefit if the non-provider panels are kept relatively narrow
C) members will pay higher coinsurance or copayments if they first see their PCPs each time
D) the plan offers no financial incentives to members to choose an in-network specialist over a non-network specialist

Question 14

The following statements are about factors that health plans should consider as they develop provider networks in rural and urban markets. Three of the statements are true, and one of the statements is false. Select the answer choice that contains the FALSE statement.

A) Compared to providers in urban areas, providers in rural areas are less likely to offer discounts to health plans in exchange for directed patient volume.
B) In urban areas, limiting the number of specialists on a panel usually affects the network's market appeal more than does limiting the number of primary care physicians.
C) The greatest opportunity to create competition in rural areas is among the specialty providers in other nearby communities.
D) Typically, hospital contracting is easier in urban areas than in rural areas.

Question 15

Federal laws--including the Ethics in Patient Referrals Act, the Health Maintenance Organization (HMO) Act of 1973, the Employee Retirement Income Security Act (ERISA), and the Federal Trade Commission Act--have impacted the ways that health plans conduct business. For instance, the Mosaic Health Plan must comply with the following federal laws in order to operate: Regulation 1: Mosaic must establish a mandated grievance resolution mechanism, including a method for members to address grievances with network providers. Regulation 2: Mosaic must not allow its providers to refer Medicare and Medicaid patients to entities in which they have a financial or ownership interest. From the answer choices below, select the response that correctly identifies the federal legislation on which Regulation 1 and Regulation 2 are based.

A) Regulation 1 - The Ethics in Patient Referrals Act Regulation 2 - The HMO Act of 1973
B) Regulation 1 - The HMO Act of 1973 Regulation 2 - The Ethics in Patient Referrals Act
C) Regulation 1 - ERISA Regulation 2 - The Federal Trade Commission Act
D) Regulation 1 - The Federal Trade Commission Act Regulation 2 - ERISA

Question 16

By definition, a measure of the extent to which a health plan member can obtain necessary medical services in a timely manner is known as

A) Network management
B) Quality
C) Cost-effectiveness
D) Accessibility

Question 17

For this question, if answer choices (A) through C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. Understanding the level of health plan penetration in a particular market can help a health plan determine which products are most appropriate for that market. Indicators of a mature health plan market include

A) Areduction in the rate of growth in health plan premium levels
B) Areduction in the level of outcomes management and improvement
C) An increase in the rate of inpatient hospital utilization
D) All of the above

Question 18

The Holiday Health Plan is preparing to enter a new market. In order to determine the optimal size of its provider panel in the new market, Holiday is conducting a competitive analysis of provider networks of the market's existing health plans. Consider whether, in conducting its competitive analysis, Holiday should seek answers to the following questions: Question 1: What are the cost-containment strategies of the health plans with increasing market shares? Question 2: What are the premium strategies of the health plans with large market shares? Question 3: What are the characteristics of health plans that are losing market share? In its competitive analysis, Holiday should most likely obtain answers to questions

A) 1, 2, and 3
B) 1 and 2 only
C) 1 and 3 only
D) 2 and 3 only

Question 19

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. One important activity within the scope of network management is ensuring the quality of the health plan's provider networks. A primary purpose of __________________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan's preestablished criteria for participation in the network.

A) authorization
B) provider relations
C) credentialing
D) utilization management

Question 20

One important aspect of network management is profiling, or provider profiling. Profiling is most often used to

A) measure the overall performance of providers who are already participants in the network
B) assess a provider's overall satisfaction with a plan's service protocols and other operational areas
C) verify a prospective provider's professional licenses, certifications, and training
D) familiarize a provider with a plan's procedures for authorizations and referrals

Question 21

When the Rialto Health Plan determines which of the emergency services received by its plan members should be covered by the health plan, it is guided by a standard which describes emergencies as medical conditions manifesting themselves by acute symptoms of sufficient severity (including severe pain) such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy. This standard, which was adopted by the NAIC in 1996, is referred to as the

A) medical necessity standard
B) prudent layperson standard
C) "all-or-none" standard
D) reasonable and customary standard

Question 22

The following statements are about the negotiation process of provider contracting. Three of the statements are true and one of the statements is false. Select the answer choice containing the FALSE statement.

A) While preparing for negotiations, the health plan usually sends the provider an application to join the provider network, a list of credentialing requirements, and a copy of the proposed provider contract, which may or may not include the proposed reimbursement schedule.
B) In general, the ideal negotiating style for provider contracting is a collaborative approach.
C) Typically, the health plan and the provider negotiate the reimbursement arrangement between the parties before they negotiate the scope of services and the contract language.
D) The actual signing of the provider contract typically takes place after negotiations are completed.

Question 23

From the following answer choices, choose the type of clause or provision described in this situation. The Aviary Health Plan includes in its provider contracts a clause or provision that places the ultimate responsibility for an Aviary plan member's medical care on the provider.

A) Cure provision
B) Hold-harmless provision
C) Evergreen clause
D) Exculpation clause

Question 24

With respect to contractual provisions related to provider-patient communications, nonsolicitation clauses prohibit providers from

A) Encouraging patients to switch from one health plan to another
B) Disclosing confidential information about the health plan's reimbursement structure
C) Dispersing confidential financial information regarding the health plan
D) Discussing alternative treatment plans with patients

Question 25

The Brice Health Plan submitted to Clarity Health Services a letter of intent indicating Brice's desire to delegate its demand management function to Clarity. One true statement about this letter of intent is that it

A) creates a legally binding relationship between Brice and Clarity
B) most likely contains a confidentiality clause committing Brice and Clarity to maintain the confidentiality of documents reviewed and exchanged in the process
C) prohibits Clarity from performing similar delegation activities for other health plans
D) most likely contains a detailed description of the functions that Brice will delegate to Clarity

Question 26

During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider's application. One true statement regarding this process is that the health plan

A) has a legal right to access a prospective provider's confidential medical records at any time
B) must limit any evaluations of a prospective provider's office to an assessment of quantitative factors, such as the number of double-booked appointments a physicianaccepts at the end of each day
C) is prohibited by law from conducting primary verification of such data as a prospective provider's scope of medical malpractice insurance coverage and federal tax identification number
D) must complete the credentialing process before a provider signs the network contract or must include in the signed document a provision that the final contract is contingent upon the completion of the credentialing process

Question 27

The provider contract that Dr. Huang Kwan has with the Poplar Health Plan includes a typical scope of services provision. The medical service that Dr. Kwan provided to Alice Meyer, a Poplar plan member, is included in the scope of services. The following statement(s) can correctly be made about this particular medical service:

A) Dr. Kwan most likely was required to seek authorization from Poplar before performing this particular service.
B) Dr. Kwan most likely was paid on a FFS basis for providing this service.
C) Both A and B
D) A only
E) B only
F) Neither A nor B

Question 28

In open panel contracting, there are several types of delivery systems. One such delivery system is the faculty practice plan (FPP). One likely result that a health plan will experience by contracting with an FPP is that the health plan will

A) be able to select most of the physicians in the FPP
B) achieve the highest level of cost effectiveness possible
C) experience limited control over utilization
D) achieve the most effective case management possible

Question 29

Health plan contract negotiations with an integrated delivery system (IDS) or a hospital are usually lengthier and more complex than negotiations with a single-specialty provider.

Question 30

The NPDB specifies the entities that are eligible to request information from the data bank, as well as the conditions under which requests are allowed. In general, entities that are eligible to request information from the NPDB include

A) medical malpractice insurers and the general public
B) medical malpractice insurers and professional societies that are screening applicants for membership
C) the general public and state licensing boards
D) state licensing boards and professional societies that are screening applicants for membership

Question 31

The following statements are about the responsibilities that providers are expected to assume under most provider contracts with health plans. Select the answer choice containing the correct statement.

A) All health plans now include in their provider contracts a statement that explicitly places responsibility for the medical care of plan members on the health plan rather than on the provider.
B) According to the wording of most provider contracts, the responsibility of providers to deliver medical services to a plan member is not contingent upon the provider's receipt of information regarding the member's eligibility for these services.
C) Most health plans include in their provider contracts a clause which requires providers to maintain open communication with plan members regarding appropriate treatment plans, even if the services are not covered by the member's health plan.
D) Most provider contracts require participating providers to discuss health plan payment arrangements with patients who are covered by the plan.

Question 32

Determine whether the following statement is true or false: The NCQA has established a Physician Organization Certification (POC) program for the purpose of certifying medical groups and independent practice associations for delegation of certain NCQA standards, including data collection and verification for credentialing and recredentialing.

Question 33

The following statement(s) can correctly be made about hospitalists. 1. The hospitalist's main function is to coordinate diagnostic and treatment activities to ensure that the patient receives appropriate care while in the hospital. 2. The hospitalist's role clearly supports the health plan concept of disease management.

A) Both 1 and 2
B) 1 only
C) 2 only
D) Neither 1 nor 2

Question 34

The Justice Health Plan is eligible to submit reportable actions against medical practitioners to the National Practitioner Data Bank (NPDB). Justice is considering whether it should report the following actions to the NPDB: Action 1--A medical malpractice insurer made a malpractice payment on behalf of a dentist in Justice's network for a complaint that was settled out of court. Action 2--Justice reprimanded a PCP in its network for failing to follow the health plan's referral procedures. Action 3--Justice suspended a physician's clinical privileges throughout the Justice network because the physician's conduct adversely affected the welfare of a patient. Action 4--Justice censured a physician for advertising practices that were not aligned with Justice's marketing philosophy. Of these actions, the ones that Justice most likely must report to the NPDB include Actions

A) 1, 2, and 3 only
B) 1 and 3 only
C) 2 and 4 only
D) 3 and 4 only

Question 35

From the following answer choices, choose the type of clause or provision described in this situation. The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.

A) Cure provision
B) Hold-harmless provision
C) Evergreen clause
D) Exculpation clause

Question 36

The provider contract between the Ocelot Health Plan and Dr. Enos Zorn, one of the health plan's participating providers, is a brief contract which includes, by reference, an Ocelot provider manual. This manual contains much of the information found in Ocelot's comprehensive provider contracts. The following statements are about Dr. Zorn's provider contract. Select the answer choice containing the correct statement.

A) All statements in the provider contract shall be deemed to be warranties, because all statements of facts contained in the contract must be true only in those respects material to the contract.
B) Because the provider manual is part of the contract, Ocelot must make sure that its provider manual is comprehensive and up-to-date.
C) Because the provider contract is a brief contract, Ocelot most likely is prohibited from amending the contract unilaterally, even if it gives Dr. Zorn advance notice of its intent to amend the contract.
D) Areas that should be covered in the provider manual, and not in the body of the contract, include any specific legal issues relevant to the contract.

Question 37

The following statements are about some of the issues surrounding the contractual responsibilities of health plans. Select the answer choice containing the correct statement.

A) Typically, health plans are required to pay completed claims within 10 days of submission. 26
B) Health plans typically are prohibited from examining the financial soundness of a self-funded employer plan that relies on the health plan to pay providers for services received by the plan's members.
C) Patient delivery is one of the most significant factors that health plans consider when determining whether provider services should be reimbursed on a capitated or fee-for-service (FFS) basis.
D) Health plans require all providers to agree to an exclusive provider contract.

Question 38

The introductory paragraph of a provider contract is generally followed by a section called the recitals. The recitals section of the contract typically specifies the

A) Purpose of the agreement
B) Manner in which the provider is to bill for services  22
C) Definitions of key terms to be used in the contract
D) Rate at which the provider will be compensated

Question 39

Participating providers in a health plan's network must undergo recredentialing on a regular basis. During recredentialing, a health plan typically reviews

A) a provider's current, updated application information, as well as provider's peer reviews and performance reports on the provider
B) a provider's current, updated application information, as well as the provider's education and prior work history
C) a provider's education and prior work history only
D) peer reviews and performance reports on a provider and the provider's prior work history only

Question 40

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. A credentials verification organization (CVO) can be certified to verify certain pertinent credentialing information, including

A) Liability claims histories of prospective providers
B) Hospital privileges of prospective providers
C) Malpractice insurance on prospective providers
D) All of the above

Question 41

The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline. Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn's PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn's dermatology services fund for the first quarter was $15,000. During the quarter, Autumn's PCPs made 90 referrals, and 20 of these referrals were classified as complicated. In determining the first quarter payment to dermatologists, Autumn would accurately calculate the value of each referral point to be

A) $111.11
B) $125.00
C) $150.00
D) $166.67

Question 42

The Walton Health Plan uses the fee-for-service pharmaceutical reimbursement approach known as the maximum allowable cost (MAC) method. If Walton's MAC list specifies a cost of 8 cents per tablet for a particular drug but the participating pharmacy pays 10 cents per tablet for the drug, then Walton will be obligated to reimburse the pharmacy for

A) 8 cents per tablet, but the pharmacy can bill the subscriber for the remaining 2 cents per tablet
B) 8 cents per tablet, and the pharmacy cannot bill the subscriber for the remaining 2 cents per tablet
C) 10 cents per tablet, but the pharmacy must refund the extra 2 cents per tablet to the subscriber
D) 10 cents per tablet, and the pharmacy is not required to refund the extra 2 cents per tablet to the subscriber

Question 43

The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method. If Gladspell's per diem contract with Ellysium is typical, then the per diem payment will cover such medical costs as

A) Laboratory tests
B) Respiratory therapy
C) Semiprivate room and board
D) Radiology services

Question 44

One reimbursement method that health plans can use for hospitals is the ambulatory payment classifications (APCs) method. APCs bear a resemblance to the diagnosis-related groups (DRGs) method of reimbursement. However, when comparing APCs and DRGs, one of the primary differences between the two methods is that only the APC method

A) is typically used for outpatient care
B) assigns a single code for treatment
C) applies to treatment received during an entire hospital stay
D) is considered to be a retrospective payment system

Question 45

One reason that an health plan would want to use the actual acquisition cost (AAC) pricing system to calculate its drug costs is that, of the systems commonly used to calculate drug costs, the AAC system

A) Provides the lowest level of cost for the health plan
B) Most closely represents what pharmacies are actually charged for prescription drugs
C) Offers the best control over multiple-source pharmaceutical products
D) Is the least expensive pricing system for the health plan to implement

Question 46

If the Oconee Health Plan reimburses its specialty care physicians (SCPs) under a typical retainer method, then Oconee pays SCPs

A) Aseparate amount for each service provided, and the payment amount is based solely on a resource-based relative value scale (RBRVS)
B) Aspecified fee that remains the same regardless of how much or how little time or effort is spent on the medical service performed
C) Aset amount each month, and Oconee reconciles its payment at periodic intervals on the basis of actual utilization
D) Aset amount of cash equivalent to a defined time period's expected reimbursable charges

Question 47

The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method. If the Ellysium subacute care unit is typical of most hospital-based subacute skilled nursing units, then this unit could be used for patients who no longer need to be in the hospital's acute care unit but who still require

A) Daily medical care and monitoring
B) Regular rehabilitative therapy
C) Respiratory therapy
D) All of the above

Question 48

The Sweeney Health Plan uses the discounted fee-for-service (DFFS) method to compensate some of its providers. Under this method of compensation, Sweeney calculates payments based on

A) The standard fees of indemnity health insurance plans, adjusted by region
B) The Medicare fee schedules used by other health plans, adjusted by region
C) Whichever amount is higher, the billed charge or the DFFS amount
D) Whichever amount is lower, the billed charge or the DFFS amount

Question 49

One true statement about the compensation arrangement known as the case rate system is that, under this system,

A) Providers stand to gain or lose based on the number and types of treatments used for each case
B) Providers have no incentives to take an active role in managing cost and utilization
C) Payors cannot adjust standard case rates to reflect the severity of the patient's condition or complications that arise from multiple medical problems
D) Payors have the opportunity to benefit from the provider's cost savings

Question 50

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen. A formulary lists the drugs and treatment protocols that are considered to be the preferred therapy for a given managed population. The Fairfax Health Plan uses the type of formulary which covers drugs that are on its preferred list as well as drugs that are not on its preferred list. This information indicates that Fairfax uses the (closed / open) formulary method. In using the formulary approach to pharmacy benefits management, Fairfax most likely experiences (higher / lower) costs for its members' prescription drugs than it would if it did not use a formulary.

A) closed / higher
B) closed / lower
C) open / higher
D) open / lower

Question 51

An health plan enters into a professional services capitation arrangement whenever the health plan

A) Contracts with a medical group, clinic, or multispecialty IPA that assumes responsibility for the costs of all physician services related to a patient's care
B) Pays individual specialists to provide only radiology services to all plan members
C) Transfers all financial risk for healthcare services to a provider organization and the provider, in turn, covers virtually all of a patient's medical expenses
D) Contracts with a primary care provider to cover primary care services only

Question 52

If a third party is responsible for injuries to a plan member of the Hope Health Plan, then Hope has a contractual right to file a claim for the resulting healthcare costs against the third party. This contractual right to recovery from the third party is known as

A) Subrogation
B) Partial capitation
C) Coordination of benefits
D) Aremedy provision

Question 53

To protect providers against business losses, many health plan-provider contracts include carve- out provisions to help providers manage financial risk. The following statements are examples of such provisions: The Apex Health Plan carves out immunizations from PCP capitations. Apex compensates PCPs for immunizations on a case rate basis. The Bengal Health Plan carves out behavioral healthcare services from the scope of PCP services because these services require specialized knowledge and skills that most PCPs do not possess. From the answer choices below, select the response that best identifies the types of carve-outs used by Apex and Bengal.

A) Apex: disease-specific carve-out Bengal: specialty services carve-out
B) Bengal: specific-service carve-out
C) Apex: specific-service carve-out
D) Bengal: disease-specific carve-out

Question 54

The Omni Health Plan is interested in expanding the specialty services it offers to its plan members and is considering contracting with the following providers of specialty services: The Apex Company, a managed vision care organization (MVCO) The Baxter Managed Behavioral Healthcare Organization (MBHO) The Cheshire Dental Health Maintenance Organization (DHMO) As part of its credentialing process, Omni would like to verify that each of these providers has met NCQA's accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for

A) Apex and Baxter only
B) Apex and Cheshire only
C) Baxter and Cheshire only
D) Baxter only

Question 55

The Ross Health Plan compensates Dr. Cecile Sanderson on a FFS basis. In order to increase the level of reimbursement that she would receive from Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The services she actually provided represented an intermediate level of service. Dr. Sanderson's action is an example of a type of false billing procedure known as

A) Cost shifting
B) Churning
C) Unbundling
D) Upcoding

Question 56

Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in

A) Slower access to BH care for plan members
B) Increased collaboration between BH providers and PCPs
C) Fewer specialized BH services for plan members
D) Decreased continuity of BH care for plan members

Question 57

The following statements can correctly be made about the advantages and disadvantages to an health plan of using the various delivery options for pharmacy services.

A) A disadvantage of using open pharmacy networks is that the health plan's control over costs is limited to setting reimbursement levels.
B) An advantage of using performance-based systems is that they tend to increase participation in the health plan's pharmacy network.
C) A disadvantage of using customized pharmacy networks is that these networks typically can be implemented only in companies with fewer than 500 employees.
D) All of these statements are correct.

Question 58

Four types of APCs are ancillary APCs, medical APCs, significant procedure APCs, and surgical APCs. An example of a type of APC known as

A) An ancillary APC is a biopsy
B) Amedical APC is radiation therapy
C) Asignificant procedure APC is a computerized tomography (CT) scan
D) Asurgical APC is an emergency department visit for cardiovascular disease

Question 59

The Athena Medical Group has purchased from the Corinthian Insurance Company individual stop-loss insurance coverage for primary and specialty care services with a $5,000 attachment point and 10 percent coinsurance. One of Athena's patients accrued $8,000 of medical costs for primary and specialty care treatment. In this situation, Athena will be responsible for paying an amount equal to

A) $300, and Corinthian is obligated to reimburse Athena in the amount of $2,700
B) $2,700, and Corinthian is obligated to reimburse Athena in the amount of $5,300
C) $5,300, and Corinthian is obligated to reimburse Athena in the amount of $2,700
D) $7,700, and Corinthian is obligated to reimburse Athena in the amount of $300

Question 60

The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline. Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn's PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn's dermatology services fund for the first quarter was $15,000. During the quarter, Autumn's PCPs made 90 referrals, and 20 of these referrals were classified as complicated. Autumn's method of reimbursing specialty providers can best be described as a

A) Disease-specific arrangement
B) Contact capitation arrangement
C) Risk adjustment arrangement
D) Withhold arrangement

Question 61

Dr. Sylvia Cimer and Dr. Andrew Donne are obstetrician/gynecologists who participate in the same provider network. Dr. Comer treats a large number of high-risk patients, whereas Dr. Donne's patients are generally healthy and rarely present complications. As a result, Dr. Comer typically uses medical resources at a much higher rate than does Dr. Donne. In order to equitably compare Dr. Comer's performance with Dr. Donne's performance, the health plan modified its evaluation to account for differences in the providers' patient populations and treatment protocols. The health plan modified Dr. Comer's and Dr. Donne's performance data by means of

A) Acase mix/severity adjustment
B) An external performance standard
C) Structural measures
D) Behavior modification

Question 62

Martin Breslin, age 72 and permanently disabled, is classified as dually-eligible. This information indicates that Mr. Breslin qualifies for coverage by both

A) Medicare and private indemnity insurance, and Medicare provides primary coverage
B) Medicare and Medicaid, and Medicare provides primary coverage
C) Medicaid and private indemnity insurance, and Medicaid provides primary coverage
D) Medicare and Medicaid, and Medicaid provides primary coverage

Question 63

In most states, workers' compensation is first-dollar and last-dollar coverage, which means that workers' compensation programs

A) Can place limits on the benefits they will pay for a given claim
B) Can deny coverage for work-related illness or injury if the employer is not at fault
C) Must pay 100% of work-related medical and disability expenses
D) Can hold employers liable for additional amounts that result from court decisions

Question 64

One true statement about the Employee Retirement Income Security Act of 1974 (ERISA) is that:

A) ERISA applies to all issuers of health insurance products, such as HMOs
B) pension plans and employee welfare plans are exempt from any regulation under ERISA
C) ERISA requires self-funded plans to comply with all state mandates affecting health insurance companies and health plans
D) the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plans

Question 65

Since 1981, states have had the option to experiment with new approaches to their Medicaid programs under the "freedom of choice" waivers. Under one such waiver, a Section 1915(b) waiver, states are allowed to

A) Give Medicaid recipients complete freedom in choosing healthcare providers
B) Give Medicaid recipients the option to choose not to enroll in a healthcare plan
C) Mandate certain categories of Medicaid recipients to enroll in health plans
D) Establish demonstration projects to test new approaches for delivering care to Medicaid recipients

Question 66

Dr. Ahmad Shah and Dr. Shantelle Owen provide primary care services to Medicare+Choice enrollees of health plans under the following physician incentive plans: Dr. Shah receives $40 per enrollee per month for providing primary care and an additional $10 per enrollee per month if the cost of referral services falls below a specified level Dr. Owen receives $30 per enrollee per month for providing primary care and an additional $15 per enrollee per month if the cost of referral services falls below a specified level The use of a physician incentive plan creates substantial risk for

A) Both Dr. Shah and Dr. Owen
B) Dr. Shah only
C) Dr. Owen only
D) Neither Dr. Shah nor Dr. Owen

Question 67

As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy CMS requirements regulating access to covered services. In order to ensure that its network provides adequate access, Brightwell must

A) Allow enrollees to determine whether they will receive primary care from a physician, nurse practitioner, or other qualified network provider
B) Base a provider's participation in the network, reimbursement, and indemnification levels on the provider's license or certification
C) Define its service area according to community patterns of care
D) Require enrollees to obtain prior authorization for all emergency or urgently needed services

Question 68

Dr. Sarah Carmichael is one of several network providers who serve on one of the Apex Health Plan's organizational committees. The committee reviews cases against providers identified through complaints and grievances or through clinical monitoring activities. If needed, the committee formulates, approves, and monitors corrective action plans for providers. Although Apex administrators and other employees also serve on the committee, only participating providers have voting rights. The committee that Dr. Carmichael serves on is a

A) Utilization management committee
B) Peer review committee
C) Medical advisory committee
D) Credentialing committee

Question 69

The provider contract that the Danube Health Plan has with the Viola Home Health Services Organization states that Danube will use a typical flat rate reimbursement arrangement to compensate Viola for the skilled nursing services it provides to Danube's plan members. A portion of the contract's reimbursement schedule is shown below: Home Health Licensed Practical Nurse (LPN): $45 per visit or $90 per diem Home Health Registered Nurse (RN): $50 per visit or $110 per diem Last month, an LPN from Viola visited a Danube plan member and provided 1Ѕ hours of home healthcare, and an RN from Viola visited another Danube plan member and provided 7 hours of home healthcare. The following statement(s) can correctly be made about Danube's payment to Viola for these services:

A) Danube most likely owes $90 for the LPN's skilled nursing services and $110 for the RN's skilled nursing services.
B) Danube's payment amount could be different from the amount called for in the reimbursement schedule if the level of care provided to one of these plan members was significantly different from the level of care normally provided by Viola's RNs and LPNs.
C) Both A and B
D) A only
E) B only
F) Neither A nor B

Question 70

Prior to the enactment of the Balanced Budget Act (BBA) of 1997, payment for Medicare-covered primary and acute care services was based on the adjusted average per capita cost (AAPCC). The AAPCC is defined as the

A) average cost of services delivered to all patients living in a specified geographic region
B) actuarial value of the deductible and coinsurance amounts for basic Medicare-covered benefits
C) fee-for-service amount that the Centers for Medicaid and Medicare Services (CMS) would pay for a Medicare beneficiary, adjusted for age, sex, and institutional status
D) average fixed monthly fee paid by all Medicare enrollees in a specified geographic region

Question 71

An increasing number of health plans offer coverage for alternative healthcare services. One such alternative healthcare service is biofeedback. Biofeedback is an approach that

A) is based on an ancient Chinese system of healing in which needles are inserted into specific sites on the body to relieve pain
B) treats diseases with tiny doses of substances which, in healthy people, are capable of producing symptoms like those of the disease being treated
C) uses electronic monitoring devices to teach a patient to develop conscious control of involuntary bodily functions, such as heart rate and body temperature
D) incorporates a variety of therapies, such as homeopathy, lifestyle modification, and herbal medicines, to support and maintain the body's ability to heal itself

Question 72

Medicaid is a joint federal and state program that provides healthcare coverage for low-income, medically needy, and disabled individuals. Under the terms of this joint sponsorship, the

A) Federal government is responsible for making all claim payments
B) Federal government is responsible for determining the basic benefits that must be provided to eligible Medicaid beneficiaries
C) State governments are responsible for setting minimum standards regarding eligibility, benefit coverage, and provider participation and reimbursement
D) State governments are responsible for establishing overall regulation of the Medicaid program

Question 73

Stop-loss insurance is designed to protect physicians who face substantial financial risk as a result of physician incentive plans. Medicare + Choice health plans must ensure that a physician has adequate stop-loss protection if the

A) physician has a patient panel that exceeds 25,000 patients
B) physician receives a bonus that is based solely on quality of care, patient satisfaction, or physician participation
C) difference between the physician's maximum potential payments and his or her minimum potential payments is less than 25% of the maximum potential payments
D) physician is subject to a withhold that is greater than 25% of his or her potential payments

Question 74

The Edgewood Health Plan uses a combination of structural, process, outcomes, and customer satisfaction measures to evaluate its network providers' performance. Edgewood would correctly use outcomes measures to evaluate a provider's

A) Compliance with specific regulatory or accrediting requirement
B) Appropriate use of specified procedures
C) Patient progress following treatment
D) Patient perceptions about how well the provider addresses medical problems

Question 75

Social health maintenance organizations (SHMOs) and Programs of All-Inclusive Care for the Elderly (PACE) are federal programs designed to provide coordinated healthcare services to the elderly. Unlike PACE, SHMOs

A) are reimbursed solely through Medicaid programs
B) provide extensive long-term care
C) are reimbursed on a fee-for-service basis
D) limit benefits to a specified maximum amount

Question 76

Franklin Pitt selected a Medicare+Choice option under which he is covered by a catastrophic health insurance policy with a high annual deductible and a $6,000 out-of-pocket expense maximum. CMS pays the premiums for the insurance policy out of the usual Medicare+Choice payment and deposits any difference between the capitated amount and the policy premium in a savings account. Mr. Pitt can use funds in the savings account to pay qualified medical expenses not covered by his insurance policy. At the end of the benefit year, Mr. Pitt can carry any remaining funds into the next benefit year. The Medicare+Choice option Mr. Pitt selected is known as a

A) coordinate care plan (CCP)
B) medical savings account (MSA) plan
C) competitive medical plan (CMP)
D) Medicare Risk HMO program

Question 77

The Elizabethan Health Plan uses a direct referral program, which means that

A) PCPs in Elizabethan's network can make most referrals without obtaining prior authorization from Elizabethan
B) PCPs in Elizabethan's network must always refer plan members to other specialists within the network
C) Elizabethan's plan members can bypass the PCP and obtain medical services from a specialist without a referral 53
D) Elizabethan's plan members must obtain referrals directly from Elizabethan

Question 78

State Medicaid agencies can contract with health plans through open contracting or selective contracting. One advantage of selective contracting is that it

A) Allows enrollees to choose from among a greater variety of health plans
B) Reduces the competition among health plans
C) Increases the ability of new, local plans to participate in Medicaid programs
D) Encourages the development of products that offer enhanced benefits and more effective approaches to health plans

Question 79

Jay Mercer is covered under his health plan's vision care plan, which includes coverage for clinical eye care but not for routine eye care. Recently, Mr. Mercer had a general eye examination and got a prescription for corrective lenses. Mr. Mercer's vision care plan will cover.

A) both the general eye examination and the prescription for corrective lenses
B) the general eye examination only
C) the prescription for corrective lenses only
D) neither the general eye examination nor the prescription for corrective lenses

Question 80

Member satisfaction surveys help an health plan determine whether its providers are consistently delivering services to plan members in a manner that lives up to member expectations. Member satisfaction surveys allow the health plan to gather information about

A) Amember's reaction to services received during a specific encounter
B) The reactions of specific subsets of the health plan's membership
C) Members' positive and negative experience with the plan's services
D) All of the above