Question 1

Greenpath Health Services, Inc., an HMO, recently terminated some providers from its network in response to the changing enrollment and geographic needs of the plan. A provision in Greenpath's contracts with its healthcare providers states that Greenpath can terminate the contract at any time, without providing any reason for the termination, by giving the other party a specified period of notice. The state in which Greenpath operates has an HMO statute that is patterned on the NAIC HMO Model Act, which requires Greenpath to notify enrollees of any material change in its provider network. As required by the HMO Model Act, the state insurance department is conducting an examination of Greenpath's operations. The scope of the on-site examination covers all aspects of Greenpath's market conduct operations, including its compliance with regulatory requirements.The contracts between Greenpath and its healthcare providers contain a termination provision known as

Accepted Answer

The provision in Greenpath's contracts that allows for termination without providing any reason is known as a "without cause" termination provision. This is different from a "breach of contract" provision, which would require a specific reason for termination such as a violation of the contract terms. It is also different from a "fair procedure" provision, which would require a process for resolving disputes or allowing the provider to challenge the termination. Finally, it is not related to "economic credentialing," which is a controversial practice that involves terminating providers based on their financial performance rather than the quality of care they provide.

Question 2

Health maintenance organizations (HMOs) seeking federal qualification under the HMO Act of 1973 and its amendments must meet requirements in four basic operational areas. One operational requirement for qualification is that an HMO must

Accepted Answer

The operational requirement for an ongoing quality assurance program that meets CMS requirements, stresses health outcomes, and provides for review by health professionals is a key requirement for HMO qualification under the HMO Act of 1973 and its amendments. While both A and B may be important for ensuring representation and diversity on the HMO's policy-making body, they are not listed as operational requirements for qualification under the HMO Act. Option D is not a requirement for HMO qualification, but rather a resource for HMOs seeking to improve the quality of care.

Question 3

In the paragraph below, a statement contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the statement. Then select the answer choice containing the two terms that you have chosen. In the case of Pacificare of Oklahoma, Inc. v. Burrage, the U.S. Court of Appeals for the Tenth Circuit considered whether ERISA preempts medical malpractice claims against health plans based on certain liability theories. In this case, the Tenth Circuit court held that ERISA (should /should not) preempt a liability claim against an HMO for the malpractice of one of its primary care physicians, and therefore the HMO was subject to a claim of (subordinated / vicarious) liability.

Accepted Answer

The statement says that the court held that ERISA "should not" preempt a liability claim against an HMO, meaning that such a claim is allowed to proceed. The liability claim in question is for malpractice of one of its primary care physicians, so the HMO would be subject to "vicarious" liability, meaning that it is held responsible for the actions of its employees. Therefore, the correct choice is D) Should not / vicarious.

Question 4

Congress enacted three clauses relating to the preemptive effect of the Employee Retirement Income Security Act of 1974 (ERISA). One of these clauses preserves from ERISA preemption any state law that regulates insurance, banking, or securities, with the exception of the exemption for self-funded employee benefit plans. This clause is called the

Accepted Answer

The clause that preserves from ERISA preemption any state law that regulates insurance, banking, or securities is called the savings clause.

Question 5

Arthur Dace, a plan member of the Bloom health plan, tried repeatedly over an extended period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr. Dace informally surveyed other Bloom plan members and found that many people were experiencing similar problems getting an appointment with this particular provider. Mr. Dace threatened to take legal action against Bloom, alleging that the health plan had deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making it difficult for patients to make appointments with Dr. Pyle. Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR) method that is quicker and less expensive than litigation. Under this ADR method, both Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who issued a decision that Bloom's utilization management practices in this case did not constitute a form of abuse. The panel's decision is legally binding on both parties. Different types of compensation arrangements in managed care plans, from fee-for-service (FFS) arrangements to capitation arrangements, lead to different types of fraud and abuse. From the answer choices below, select the response that identifies the form of abuse in which Bloom is allegedly engaging, according to Mr. Dace's complaint, and whether this form of abuse is more likely to occur in FFS compensation arrangements or in capitation arrangements.

Accepted Answer

The form of abuse alleged by Mr. Dace is underutilization, which is more likely to occur in capitation arrangements. In capitation, providers receive a fixed amount per patient, incentivizing them to limit services to reduce costs.

Question 6

From the following answer choices, choose the term that best corresponds to this description. The SureQual Group is a group of practicing physicians and other healthcare professionals paid by the federal government to review services ordered or furnished by other practitioners in the same medical fields for the purpose of determining whether medical services provided were reasonable and necessary, and to monitor the quality of care given to Medicare patients.

Accepted Answer

The described group fits the definition of a peer review organization (PRO), which is specifically contracted by the federal government to review services provided to Medicare patients. Health insuring organizations (HIOs) focus on providing insurance coverage, independent practice associations (IPAs) are networks of independent practices that contract with insurance companies, and physician practice management (PPM) companies provide administrative services to medical practices.

Question 7

One typical difference between a for-profit health plan's board of directors and a not-for-profit health plan's board of directors is that the directors in a for-profit health plan

Accepted Answer

For-profit health plan's board of directors are accountable to shareholders and have a profit motive, whereas not-for-profit health plan's board of directors are accountable to plan members and the community and do not have a profit motive. Choices A, B, and D are not accurate differences between for-profit and not-for-profit health plan's board of directors.

Question 8

There are several exceptions to the Ethics in Patient Referrals Act and its amendments (the Stark laws), which prohibit a physician from referring Medicare or Medicaid patients for certain designated services or supplies provided by entities in which the physician has a financial interest. Consider whether the situations described below qualify as exceptions to the Stark laws: Situation A: Dr. Wong is a physician in the Marvel Health Plan's provider network and has a financial relationship with Marvel arising from the health plan's compensation for his services. Marvel is not a prepaid health plan. Situation B: Dr. Ryder is a physician in the provider network of the Glen Health Plan, which is not a prepaid health plan. In situations of medical necessity, Dr. Ryder refers Glen patients to a physical therapy clinic that leases office space from him. Situation C: Dr. Yost has a compensation arrangement with a health plan for providing health services under the Medicare+Choice program. An arrangement that is exempt from the Stark laws is described in

Accepted Answer

Dr. Yost has a compensation arrangement with a health plan for providing health services under the Medicare+Choice program. This arrangement is exempt from the Stark laws because it is a prepaid health plan.

Question 9

The following statements are about various provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Three of the statements are true and one statement is false. Select the answer choice that contains the FALSE statement.

Accepted Answer

Section 231(h) of HIPAA, which amended the Social Security Act, prohibits health plans with Medicare contracts from providing enrollees with value-added services such as discounted memberships to health clubs.

Question 10

Arthur Dace, a plan member of the Bloom Health Plan, tried repeatedly over an extended period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr. Dace informally surveyed other Bloom plan members and found that many people were experiencing similar problems getting an appointment with this particular provider. Mr. Dace threatened to take legal action against Bloom, alleging that the health plan had deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making it difficult for patients to make appointments with Dr. Pyle. Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR) method that is quicker and less expensive than litigation. Under this ADR method, both Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who issued a decision that Bloom's utilization management practices in this case did not constitute a form of abuse. The panel's decision is legally binding on both parties. This information indicates that Bloom resolved its dispute with Mr. Dace by using an ADR method known as:

Accepted Answer

The ADR method used by Bloom and Mr. Dace is arbitration, as it involves presenting evidence to a panel of experts who issue a legally binding decision. Corporate risk management involves identifying and mitigating risks to a company, an ombudsman program provides an independent channel for dispute resolution within an organization, and an ethics committee typically advises on ethical issues rather than resolving disputes.

Question 11

There are several approaches to the interagency division of responsibility for managed care entity (MCE) oversight. In State M, the state Medicaid agency, the state department of health, and the state insurance department are all responsible for ensuring that quality improvement programs are in place among the same group of MCEs and that these programs meet each agency's rules and regulations for such programs. This information indicates that State M uses the approach known as the

Accepted Answer

The concurrent model involves multiple agencies sharing responsibility for oversight of MCEs, with each agency having its own specific areas of focus and rules/regulations to enforce. In this case, the state Medicaid agency, department of health, and insurance department all have responsibility for ensuring quality improvement programs are in place among the same group of MCEs, indicating a concurrent model approach.

Question 12

States may impose nominal deductibles, coinsurance, or copayments on some Medicaid recipients for certain services. Services for which states can require copayments from Medicaid recipients include:

Accepted Answer

The answer of States may impose nominal deductibles, coinsurance, or...

Question 13

The following statements are about market conduct examinations of health plans. Select the answer choice that contains the correct statement.

Accepted Answer

Market conduct examinations of a health plan's advertising and sales materials do include comparing the advertising materials to the policies they advertise. This helps ensure that the advertising is not misleading or deceptive. Multistate examinations can be appropriate for financial examinations, but regulatory requirements must be coordinated across states to ensure consistency in the examination process. Once an examination report is provided to the health plan, the plan is given an opportunity to respond and address any deficiencies identified in the report. State insurance departments are not required to follow federal sentencing guidelines when imposing sanctions on health plans.

Question 14

The Hanford Health Plan has delegated the credentialing of its providers to the Sienna Group, a credential verification organization (CVO). If the contract between Hanford and Sienna complies with all of the National Committee for Quality Assurance (NCQA) guidelines for delegation of credentialing, then this contract

Accepted Answer

According to the NCQA guidelines, a delegated credentialing contract should include both the transfer of rights to terminate or suspend providers and a process for Hanford to evaluate Sienna's performance in credentialing providers. Therefore, both option A and B are included in a compliant contract.

Question 15

The following statements appear in the Twilight Health Plan's strategic plan: Increase the percentage of preventive health interventions for total eligible membership during each of the next three calendar years for the following services: mammography, Pap smears, immunizations, and first trimester visits for prenatal mothers Improve customer satisfaction on an annual basis for each of the next three calendar years, as measured by satisfaction surveys for members, providers, and employer groups Increase by 30% the number of claims processed by the automated claim payment system and reduce by 10% the cost of paying claims during the next three years These statements are examples of Twilight's

Accepted Answer

These statements are specific, measurable goals that the Twilight Health Plan aims to achieve, which are characteristic of corporate objectives.

Question 16

TRICARE, a military healthcare program, offers eligible beneficiaries three options for healthcare services: TRICARE Prime, TRICARE Extra, and TRICARE Standard. With respect to plan features, both an annual deductible and claims filing requirements must be met, regardless of whether care is delivered by network providers, under

Accepted Answer

The answer of TRICARE, a military healthcare program, offers eligible...

Question 17

The Opal Health Plan complies with all of the provisions of the Newborns' and Mothers' Health Protection Act of 1996 (NMHPA). Samantha Hill and Debra Chao are Opal enrollees. Ms. Hill was nhospitalized for a cesarean birth, and Ms. Chao was hospitalized for a normal delivery. From the following answer choices, select the response that indicates the minimum hospital stay for which Opal, under NMHPA, must provide benefits for Ms. Hill and Ms. Chao.

Accepted Answer

The NMHPA requires health plans to provide at least 96 hours of hospital stay coverage for cesarean births and 48 hours for normal deliveries.

Question 18

One provision of the Mental Health Parity Act of 1996 (MHPA) is that the MHPA prohibits group health plans from

Accepted Answer

The Mental Health Parity Act of 1996 prohibits group health plans from setting a cap for a group member's lifetime mental health benefits that is lower than the cap for the member's lifetime medical health benefits.

Question 19

SoundCare Health Services, an MCO, recently conducted a situation analysis. One step in this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activityprovided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detecting violations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program. By definition, the activity that SoundCare conducted when it examined its strengths, weaknesses, and capabilities is known as

Accepted Answer

The activity described in the scenario is an internal assessment, which involves examining an organization's current activities and capabilities, as well as identifying strengths and weaknesses. An environmental analysis involves assessing the external factors that affect an organization, such as competition and regulatory changes, while an environmental forecast involves predicting future changes in the external environment. A community analysis focuses on the local community and its needs, and is not relevant to the scenario.

Question 20

Solvency standards for Medicare provider-sponsored organizations (PSOs) are divided into three parts: (1) the initial stage, (2) the ongoing stage, and (3) insolvency. In the initial stage, prior CMS approval, a Medicare PSO typically must have a minimum net worth of

Accepted Answer

According to CMS regulations, in the initial stage, prior CMS approval, a Medicare PSO typically must have a minimum net worth of $1,500,000.

Exam 2: Governance and Regulation