Question 1

In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it

Accepted Answer

HIPAA guarantees access to healthcare coverage for small businesses and previously covered individuals who meet specified eligibility requirements, ensuring that they can obtain insurance even if they have pre-existing conditions.

Question 2

From the following answer choices, choose the term that best matches the description. Members of a physician-hospital organization (PHO) denied membership to a physician solely because the physician has admitting privileges at a competing hospital.

Accepted Answer

A group boycott is when competitors agree to refuse to do business with a particular person or company, often in order to put pressure on them to change their practices. In this case, the PHO members are refusing to admit a physician solely because they have admitting privileges at a competing hospital.

Question 3

A population's demographic factors--such as income levels, age, gender, race, and ethnicity--can influence the design of provider networks serving that population. With respect to these demographic factors, it is correct to say that

Accepted Answer

A population with a higher proportion of women typically requires more providers than does a population that is predominantly male because women generally seek healthcare services more frequently than men, including preventive care and reproductive services. Option A is not correct because lower-income populations have a higher incidence of preventable illnesses and delayed treatment, rather than chronic illnesses. Option B is not correct because young men are generally less likely to seek healthcare services than other groups, and may not be attached to particular providers. Option D is not correct because recognizing racial and ethnic differences in the member population is important for ensuring cultural competence in healthcare delivery and addressing healthcare disparities.

Question 4

The following statement(s) can correctly be made about the TRICARE managed healthcare program of the U.S. Department of Defense. 1. Active-duty military personnel are automatically enrolled in TRICARE's HMO option (TRICARE Prime). 2. Eligible family members and dependents can enroll in TRICARE Prime, the PPO plan (TRICARE Extra), or an indemnity plan (TRICARE Standard).

Accepted Answer

Both statements are correct. Active-duty military personnel are automatically enrolled in TRICARE Prime, which is an HMO option. Eligible family members and dependents have the option to enroll in TRICARE Prime, TRICARE Extra (PPO plan), or TRICARE Standard (indemnity plan).

Question 5

Network managers rely on a health plan's claims administration department for much of the information needed to manage the performance of providers who are not under a capitation arrangement. Examining claims submitted to a health plan's claims administration department enables the health plan to

Accepted Answer

Examining claims submitted to a health plan's claims administration department enables the health plan to determine the number of healthcare services delivered to plan members, monitor the types of services provided by the health plan's entire provider network, and evaluate providers' practice patterns and compliance with the health plan's procedures for the delivery of care. Therefore, option D is the best choice.

Question 6

The Aegean Health Plan delegated its utilization management (UM) program to the Silhouette IPA. Silhouette, in turn, transferred authority for case management to Brandon Health Services. In this situation, Brandon is best described as the

Accepted Answer

The answer of The Aegean Health Plan delegated its utilization...

Question 7

Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be

Accepted Answer

To calculate the annual network rental cost, we need to multiply the premium PMPM by the total number of members and 12 months.

Premium PMPM = $2.52 
Total number of members = 9,000

Annual network rental cost = Premium PMPM x Total number of members x 12 months 
= $2.52 x 9,000 x 12 
= $272,160

Therefore, the answer is choice C.

Question 8

Open panel health plans can contract with individual providers or with various provider groups when developing their networks. The following statements are about factors that an open panel health plan might consider in contracting with different types of provider organizations. Select the answer choice that contains the correct statement.

Accepted Answer

Contracting with an IDS allows the health plan to quickly establish a network and compete in an already competitive market. Contracting with a multispecialty group can provide both specialty consultants and PCPs. A health plan contracting with an IPA may have limited ability to select and deselect physicians. Contracting with an IDS does not eliminate antitrust risk.

Question 9

The Festival Health Plan is in the process of recruiting physicians for its provider network. Festival requires its network physicians to be board certified. The following individuals are provider applicants whose qualifications are being considered: Applicant 1 has completed his surgical residency, and he recently passed a qualifying examination in his field. Applicant 2 has completed her residency in dermatology, and she is scheduled to take qualifying examinations in the next Six months. Applicant 3 completed his residency in pediatric medicine six years ago, but he has not yet passed a qualifying examination in his field. With regard to these applicants, it can correctly be stated that only

Accepted Answer

The question states that Festival Health Plan requires its network physicians to be board certified. Only Applicant 1 is board certified as he recently passed a qualifying examination in his field. Applicant 2 is scheduled to take qualifying examinations in the next six months, and Applicant 3 has not yet passed a qualifying examination in his field. Therefore, the only applicant who meets the requirement for board certification is Applicant 1.

Question 10

The following statements are about the specialist component of a provider panel. Select the answer choice containing the correct statement.

Accepted Answer

It is ideal for a health plan to have every specialist category represented on its provider panel with appropriate geographic distribution, in order to provide comprehensive care to its members. The other statements (B, C, and D) are incorrect.

Question 11

Health plans are required to follow several regulations and guidelines regarding the access and adequacy of their provider networks. The Federal Employee Health Benefits Program (FEHBP) regulations, for example, require that health plans

Accepted Answer

The answer of Health plans are required to follow several...

Question 12

Provider panels can be either narrow or broad. Compared to a similarly sized health plan that uses a broad provider panel, a health plan that uses a narrow provider panel most likely can expect to

Accepted Answer

A narrow provider panel means that the health plan has fewer providers within their network. This often results in better negotiating power for the health plan in terms of contracts with providers, leading to lower provider relations costs. However, it may result in increased difficulty for members to access care, which could lead to lower member satisfaction and retention rates.

Question 13

Health plans use a variety of sources to find candidates to recruit for their provider networks. In general, two of the most effective methods of finding candidates are through

Accepted Answer

Word of mouth and direct mail are considered effective methods for recruiting candidates for provider networks because they leverage personal recommendations and targeted outreach.

Question 14

In contracting with providers, a health plan can use a closed panel or open panel approach. One statement that can correctly be made about an open panel health plan is that the participating providers

Accepted Answer

An open panel health plan allows participating providers to operate out of their own offices and typically does not restrict them from seeing patients who are members of other health plans. However, providers still need to meet certain qualifications set by the health plan, such as licensing and credentialing requirements.

Question 15

Salvatore Arris is a member of the Crescent Health Plan, which provides its members with a full range of medical services through its provider network. After suffering from debilitating headaches for several days, Mr. Arris made an appointment to see Neal Prater, a physician's assistant in the Crescent network who provides primary care under the supervision of physician Dr. Anne Hunt. Mr. Prater referred Mr. Arris to Dr. Ginger Chen, an ophthalmologist, who determined that Mr. Arris' symptoms were indicative of migraine headaches. Dr. Chen prescribed medicine for Mr. Arris, and Mr. Arris had the prescription filled at a pharmacy with which Crescent has contracted. The pharmacist, Steven Tucker, advised Mr. Arris to take the medicine with food or milk. In this situation, the person who functioned as an ancillary service provider is

Accepted Answer

Steven Tucker, the pharmacist, functioned as an ancillary service provider by advising Mr. Arris on how to properly take the medicine prescribed by Dr. Chen. Ancillary service providers are individuals or organizations that provide support services to primary healthcare providers. In this scenario, Mr. Prater, Dr. Hunt, and Dr. Chen are primary healthcare providers who directly diagnose, treat or manage a patient's condition.

Question 16

From the following answer choices, choose the term that best matches the description. An integrated delivery system (IDS), which controls most providers in a particular specialty, agrees to provide that specialty service to a health plan only on the condition that the health plan agree to contract with the IDS for other services.

Accepted Answer

This scenario describes a tying arrangement, where the IDS ties the provision of the specialty service to the health plan to the health plan's agreement to contract with the IDS for other services.

Question 17

With respect to hiring practices, one step that a health plan most likely can take to avoid violating the terms of the Americans with Disabilities Act (ADA) is to

Accepted Answer

According to ADA guidelines, employers can only require a medical examination after making a conditional offer of employment. This ensures that job candidates are not discriminated against based on their disability or health status during the hiring process. Therefore, making a conditional offer and then requiring an examination is the best step a health plan can take to avoid violating the ADA. Options A and B are not allowed under the ADA, as they involve probing into an applicant's health status before a job offer is made. Option D only pertains to illegal substance use and does not cover disabilities.

Question 18

Most health plan contracts provide an outline of the criteria that a healthcare service must meet in order to be considered "medically necessary." Typically, in order for a healthcare service to be considered medically necessary, the service provided by a physician or other healthcare provider to identify and treat a member's illness or injury must be

Accepted Answer

In order for a healthcare service to be considered medically necessary, it must fulfill all three requirements listed in choices A, B, and C. The service must be consistent with the symptoms or diagnosis, furnished in the least intensive setting required, and in compliance with the standards of good medical practice. Therefore, the correct answer is D, all of the above.

Question 19

Some states have enacted any willing provider laws. From the perspective of the health plan industry, one drawback of any willing provider laws is that they often result in a reduction of a plan's

Accepted Answer

Any willing provider laws require health plans to accept any provider willing to meet the terms and conditions of the plan, which can limit the plan's ability to monitor and control utilization effectively.

Question 20

The actual number of providers included in a provider network may be based on staffing ratios. Staffing ratios relate the number of

Accepted Answer

Staffing ratios typically relate the number of providers in a plan's network to the number of enrollees in the plan. This helps to ensure that there are enough providers to meet the healthcare needs of the plan's members.

Exam 4: Network Management

In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA) , which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it