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NEW QUESTION 1
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)
Answer: C
NEW QUESTION 2
The provider contract that Dr. Laura Cartier has with the Sailboat health plan includes a section known as the recitals. Dr. Cartier's contract includes the following statements:
- A. A statement that identifies the purpose of the contract
- B. A statement that defines in legal terms the parties to the contract
- C. A statement that identifies the Sailboat products to be covered by the contractOf these statements, the ones that are likely to be included in the recitals section of D
- D. Cartier's contract are statements:
- E. A, B, and C
- F. A and B only
- G. A and C only
- H. B and C only
Answer: A
NEW QUESTION 3
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.
- A. True
- B. False
Answer: A
NEW QUESTION 4
When evaluating the success of providers in meeting standards, a health plan must make adjustments for case mix or severity. One true statement about case mix/severity adjustments is that they:
- A. Typically are more important in measuring the performance of PCPs than they are in measuring the performance of specialists
- B. Help compensate for any unusual factors that may exist in a provider's patient population or in a particular patient
- C. Tend to increase the number of providers who are considered to be outliers
- D. Allow for a more equitable comparison of data between providers of outpatient care but not providers of inpatient care
Answer: B
NEW QUESTION 5
The Foxfire Health Plan, which has 20,000 members, contracts with dermatologists on a contact capitation basis. The contact capitation arrangement has the following features:
Foxfire distributes the money in the contact capitation fund once each quarter and the distribution is based on the point totals accumulated by each dermatologist.
Foxfire's per member per month (PMPM) capitation for dermatology services is $1.
The dermatologist receives 1 point for each new referral that is not classified as a complicated referral and 1.5 points for each new referral that is classified as complicated.
During the first quarter, Foxfire's PCPs made 450 referrals to dermatologists and 100 of these referrals were classified as complicated. One dermatologist, Dr. Shareef Rashad, received 42 of these referrals; 6 of his referrals were classified as complicated. Statements that can correctly be made about Foxfire's contact capitation arrangement include:
- A. that the value of each referral point for the first quarter was $120
- B. that the value of Foxfire's contact capitation fund for dermatologists for the first quarter was $20,000
- C. that the payment that Foxfire owed D
- D. Rashad for the first quarter was $6,120
- E. all of the above
Answer: A
NEW QUESTION 6
Dr. Eve Barlow is a specialist in the Amity Health Plan’s provider network. Dr. Barlow’s provider contract with Amity contains a typical most-favored-nation arrangement. The purpose of this arrangement is to
- A. Require D
- B. Barlow and Amity to use arbitration to resolve any disputes regarding the contract
- C. Specify that the contract is to be governed by the laws of the state in which Amity has its headquarters
- D. Require D
- E. Barlow to charge Amity her lowest rate for a medical service she has provided to an Amity plan member, even if the rate is lower than the price negotiated in the contract
- F. State that the contract creates an employment or agency relationship, rather than an independent contractor relationship, between D
- G. Barlow and Amity
Answer: C
NEW QUESTION 7
Decide whether the following statement is true or false:
The organizational structure of a health plan’s network management function often depends on the size and geographic scope of the health plan. With respect to the size of a health plan, it is correct to say that smaller health plans typically have less integration and more specialization of roles than do larger health plans.
- A. True
- B. False
Answer: B
NEW QUESTION 8
The two basic approaches that Medicaid uses to contract with health plans are open contracting and selective contracting. One true statement about these approaches to contracting is that:
- A. Open contracting requires health plans to meet minimum performance standards outlined in a state's request for proposal (RFP)
- B. Open contracting makes it possible for the Medicaid agency to offer enrollment volume guarantees
- C. Selective contracting requires any health plan that meets the state's performance standards and the federal Medicaid requirements to enter into a Medicaid contract
- D. Selective contracting requires health plans to bid competitively for Medicaid contracts
Answer: D
NEW QUESTION 9
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
Answer: C
NEW QUESTION 10
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
Answer: D
NEW QUESTION 11
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 1½ 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
Answer: C
NEW QUESTION 12
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
Answer: B
NEW QUESTION 13
The Walnut Health Plan provides a number of specialty services for its members. Walnut offers coverage of alternative healthcare, including coverage of treatment methods such as homeopathy and naturopathy. Walnut also offers home healthcare services, and it contracts with home healthcare providers on a non-risk basis to the health plan. The following statements are about the specialty services offered by Walnut. Select the answer choice containing the correct statement:
- A. Homeopathy treats diseases by using small doses of substances which, in healthy people, are capable of producing symptoms like those of the disease being treated.
- B. Naturopathy is an approach to healthcare that uses electronic monitoring devices to teach a patient to develop conscious control of involuntary bodily functions, such as heart rate.
- C. Under a non-risk contract, Walnut most likely transfers the responsibility for arranging home healthcare to the home healthcare provider organizations.
- D. Federal law allows Walnut to contract with a home healthcare provider organization only if the provider organization has received accreditation by the Utilization Review Accreditation Commission (URAC).
Answer: A
NEW QUESTION 14
One difference between a fee-for-service (FFS) reimbursement arrangement and capitation is that the FFS arrangement:
- A. Is a prospective payment system, whereas capitation is a retrospective payment system
- B. Has a potential to induce providers to underutilize medical resources, whereas capitation does not have this potential disadvantage
- C. Bases the amount of reimbursement on the actual medical services delivered, whereas reimbursement under capitation is independent of the actual volume and cost of services provided
- D. Is most often used by health plans to reimburse healthcare facilities, whereas capitation is most often used by health plans to reimburse specialty care providers
Answer: C
NEW QUESTION 15
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 physiciansown the HMO
- D. encourage incorporated HMOs to obtain profits from their provisions of physician professional services
Answer: C
NEW QUESTION 16
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