NEW QUESTION 1

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

Answer: D

NEW QUESTION 2

The provider contract that Dr. Bijay Patel has with the Arbor Health Plan includes a no- balance-billing clause. The purpose of this clause is to:

• A. prohibit D
• B. Patel from collecting payments from Arbor plan members for medical services that he provided them, even if the services are explicitly excluded from the benefit plan
• C. allow D
• D. Patel to bill patients for services only if the services are considered to be medically necessary
• E. establish the guidelines used to determine if Arbor is the primary payor of benefits in a situation in which an Arbor plan member is covered by more than one health plan
• F. require D
• G. Patel to accept Arbor's payment as payment in full for medical services that he provides to Arbor plan members

Answer: D

NEW QUESTION 3

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.

Answer: D

NEW QUESTION 4

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

Answer: C

NEW QUESTION 5

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

Answer: B

NEW QUESTION 6

The Octagon Health Plan includes a typical indemnification clause in its provider contracts. The purpose of this clause is to require Octagon’s network providers to

• A. Agree not to sue or file claims against an Octagon plan member for covered services
• B. Reimburse Octagon for costs, expenses, and liabilities incurred by the health plan as a result of a provider’s actions
• C. Maintain the confidentiality of the health plan’s proprietary information
• D. Agree to accept Octagon’s payment as payment in full and not to bill members for anything other than contracted copayments, coinsurance, or deductibles

Answer: B

NEW QUESTION 7

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

Answer: A

NEW QUESTION 8

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

• A. M
• B. Prater
• C. D
• D. Hunt
• E. D
• F. Chen
• G. M
• H. Tucker

Answer: D

NEW QUESTION 9

The following statement(s) can correctly be made about contracting and reimbursement of specialty care physicians (SCPs):

• A. Typically, a health plan should attempt to control utilization of SCPs before attempting to place these providers under a capitation arrangement.
• B. Forms of specialty physician reimbursement used by health plans include a retainer and a bundled case rate.
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: A

NEW QUESTION 10

Health plans typically conduct two types of reviews of a provider's medical records: an evaluation of the provider's medical record keeping (MRK) practices and a medical record review (MRR). One true statement about these types of reviews is that:

• A. An MRK covers the content of specific patient records of a provider.
• B. The NCQA requires an examination of MRK with all of a health plan's office evaluations.
• C. An MRR includes a review of the policies, procedures, and documentation standards the provider follows to create and maintain medical records.
• D. The NCQA requires MRR for both credentialing and recredentialing of providers in a health plan's network.

Answer: A

NEW QUESTION 11

Grant Pelham is covered by both a workers’ compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.
Mr. Pelham’s group health insurance plan and workers’ compensation both provide benefits to cover expenses incurred as a result of illness or injury. However, unlike traditional group insurance coverage, workers’ compensation

• A. Provides reimbursement for lost wages
• B. Requires employees who suffer a work-related illness or injury to obtain care from specified network providers
• C. Covers all injuries and illnesses, regardless of their cause
• D. Requires employees to share the cost of treatment through deductible, coinsurance, and benefit limits

Answer: A

NEW QUESTION 12

Following statements are about accreditation of health plans:

• A. The National Committee for Quality Assurance (NCQA) serves as the primary accrediting agency for most health maintenance organizations (HMOs).
• B. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has developed standards that can be used for the accreditation of hospitals, but not for the accreditation of health plan provider networks or health plan plans.
• C. States are required to adopt the model standards developed by the National Association of Insurance Commissioners (NAIC), an organization of state insurance regulators that develops standards to promote uniformity in insurance regulations.
• D. Accreditation is an evaluative process in which a health plan undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the federal government or by the state governments.

Answer: A

NEW QUESTION 13

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

Answer: A

NEW QUESTION 14

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

Answer: A

NEW QUESTION 15

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.

Answer: C

NEW QUESTION 16

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

• A. determine the number of healthcare services delivered to plan members
• B. monitor the types of services provided by the health plan’s entire provider network
• C. evaluate providers’ practice patterns and compliance with the health plan’s procedures for the delivery of care
• D. all of the above

Answer: D

NEW QUESTION 17

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

Answer: A

NEW QUESTION 18
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