NEW QUESTION 1

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

Answer: D

NEW QUESTION 2

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

Answer: C

NEW QUESTION 3

Although ambulatory payment classifications (APCs) bear some resemblance to diagnosis- related groups (DRGs), there are significant differences between APCs and DRGs. One of these differences is that APCs:

• A. typically allow for the assignment of multiple classifications for an outpatient visit
• B. always apply to a patient's entire hospital stay
• C. typically serve as a payment system for inpatient services
• D. typically include reimbursements for professional fees

Answer: A

NEW QUESTION 4

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

Answer: C

NEW QUESTION 5

The Tuba Health Plan recently underwent an accreditation process under a program known as Accreditation '99, which includes selected Health Employer Data and Information Set (HEDIS) measures. Under Accreditation '99, Tuba received a rating of Excellent. The following statement(s) can correctly be made about this quality assessment of Tuba's operations:

• A. In arriving at its rating of Excellent for Tuba, the Accreditation '99 program most likely focused on Tuba's demonstrated results and evaluated the processes that Tuba used to achieve those results.
• B. Tuba is required to report all HEDIS results to the NAIC.
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: B

NEW QUESTION 6

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

Answer: C

NEW QUESTION 7

The following statements describe two types of HMOs:
The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.
The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.
Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.
Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:
The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents
per tablet for this drug.
The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.
From the following answer choices, select the response that best identifies Elm and Treble:

• A. Elm: open access (OA) HMO Treble: direct access HMO
• B. Elm: open access (OA) HMO Treble: gatekeeper HMO
• C. Elm: direct access HMO Treble: open access (OA) HMO
• D. Elm: direct access HMO Treble: gatekeeper HMO

Answer: C

NEW QUESTION 8

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 9

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service
(DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:

• A. D
• B. Enberg's young patients receive appropriate immunizations at the right ages
• C. D
• D. Enberg's young patients receive appropriate immunizations at the right ages
• E. The condition of one of D
• F. Enberg's patients improved after the patient received medical treatment from D
• G. Enberg
• H. D
• I. Enberg's procedures are adequate for ensuring patients' access to medical care

Answer: A

NEW QUESTION 10

The Medea Clinic is a network provider for Delphic Healthcare. Delphic transferred the contract it held with Medea to the Elixir HMO, an entity that was not party to the original contract. The process by which Delphic transferred the contract it held with Medea to Elixir is known as

• A. Most-favored- nation arrangement
• B. Alimit on action
• C. Aconsideration
• D. An assignment

Answer: D

NEW QUESTION 11

The Aztec Health Plan has a variety of organizational committees related to quality and utilization management. These committees include the medical advisory committee, the credentialing committee, the utilization management committee, and the quality management committee. Of these committees, the one that most likely is responsible for providing oversight of Aztec's inpatient concurrent review process is the:

• A. medical advisory committee
• B. credentialing committee
• C. utilization management committee
• D. quality management committee

Answer: C

NEW QUESTION 12

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

Answer: C

NEW QUESTION 13

The following statements are about managed dental care. Three of these statements are true, and one is false. Select the answer choice containing the FALSE statement.

• A. Managed dental care is federally regulated.
• B. Dental HMOs typically need very few healthcare facilities because almost all dental services are delivered in an ambulatory care setting.
• C. Currently, there are no nationally recognized standards for quality in managed dental care.
• D. Processes for selecting dental care providers vary greatly according to state regulationson managed dental care networks and the health plan’s standards.

Answer: A

NEW QUESTION 14

The following statements are about waivers and the Medicaid program. Select the answer choice containing the correct statement:

• A. The Balanced Budget Act (BBA) of 1997 eliminated the need for states to make formal applications for waivers.
• B. Section 1115 waivers allow states to bypass the Medicaid program's usual requirement of giving recipients complete freedom of choice in selecting providers.
• C. Title XVIII waivers allow states to mandate certain categories of Medicaid recipients to enroll in health plan plans.
• D. Section 1915(b) waivers allow states to establish demonstration projects in order to test new approaches to benefits and services provided by Medicaid.

Answer: A

NEW QUESTION 15

Before or during the orientation process, health plans generally provide new network providers with a provider manual. One of the primary purposes of the provider manual is to

• A. Provide a directory of contracted providers
• B. Help providers and their staffs develop methods of improving the operation of their practices
• C. Provide feedback to providers regarding their performance
• D. Reinforce and document contractual provisions

Answer: D

NEW QUESTION 16

One true statement about the Medicaid program in the United States is that:

• A. The federal financial participation (FFP) in a state's Medicaid program ranges from 20% to 40% of the state's total Medicaid costs
• B. Medicaid regulations mandate specific minimum benefits, under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, for all Medicaid recipients younger than age 30
• C. The individual states have responsibility for administering the Medicaid program
• D. Non-disabled adults and children in low-income families account for the majority of direct Medicaid spending

Answer: C

NEW QUESTION 17

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

• A. Applicants 1 and 2 are board certified
• B. Applicants 2 and 3 are board certified
• C. Applicant 1 is board certified
• D. Applicant 3 is board certified

Answer: C

NEW QUESTION 18
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