NEW QUESTION 1

The provider contract between the Regal Health Plan and Dr. Caroline Quill contains a type of termination clause known as termination without cause. One true statement about this clause is that it

• A. Requires Regal to send a report to the appropriate accrediting agency if the health plan terminates D
• B. Quill’s contract without cause
• C. Requires that Regal must base its decision to terminate D
• D. Quill’s contract on clinical criteria only
• E. Allows either Regal or D
• F. Quill to terminate the contract at any time, without any obligation to provide a reason for the termination or to offer an appeals process
• G. Allows Regal to terminate D
• H. Quill’s contract at the time of contract renewal only, without any obligation to provide a reason for the termination or to offer an appeals process

Answer: C

NEW QUESTION 2

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 3

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 4

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 5

The following statements are about the delegation of network management activities from a health plan to another party. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:

• A. The NCQA requires a health plan to conduct all delegation oversight functions rather than delegating the responsibility for oversight to another entity.
• B. Credentialing and UM activities are the most frequently delegated functions, whereas delegation is less common for quality management (QM) and preventive health services.
• C. One reason that a health plan may choose to delegate a function is because the health plan's staff seeks external expertise for the delegated activity.
• D. When the health plan delegates authority for a function, it transfers the power to conduct the function on a day-to-day basis, as well as the ultimate accountability for the function.

Answer: D

NEW QUESTION 6

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).

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: A

NEW QUESTION 7

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.
Autumn’s method of reimbursing specialty providers can best be described as a

• A. Disease-specific arrangement
• B. Contact capitation arrangement
• C. Risk adjustment arrangement
• D. Withhold arrangement

Answer: B

NEW QUESTION 8

The provider contract between the Ocelot Health Plan and Dr. Enos Zorn, one of the health plan’s participating providers, is a brief contract which includes, by reference, an Ocelot provider manual. This manual contains much of the information found in Ocelot’s comprehensive provider contracts. The following statements are about Dr. Zorn’s provider contract. Select the answer choice containing the correct statement.

• A. All statements in the provider contract shall be deemed to be warranties, because all statements of facts contained in the contract must be true only in those respects material to the contract.
• B. Because the provider manual is part of the contract, Ocelot must make sure that its provider manual is comprehensive and up-to-date.
• C. Because the provider contract is a brief contract, Ocelot most likely is prohibited from amending the contract unilaterally, even if it gives D
• D. Zorn advance notice of its intent to amend the contract.
• E. Areas that should be covered in the provider manual, and not in the body of the contract, include any specific legal issues relevant to the contract.

Answer: B

NEW QUESTION 9

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 10

The Ross Health Plan compensates Dr. Cecile Sanderson on a FFS basis. In order to increase the level of reimbursement that she would receive from Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The services she actually provided represented an intermediate level of service. Dr. Sanderson’s action is an example of a type of false billing procedure known as

• A. Cost shifting
• B. Churning
• C. Unbundling
• D. Upcoding

Answer: D

NEW QUESTION 11

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 12

One reason that an health plan would want to use the actual acquisition cost (AAC) pricing system to calculate its drug costs is that, of the systems commonly used to calculate drug costs, the AAC system

• A. Provides the lowest level of cost for the health plan
• B. Most closely represents what pharmacies are actually charged for prescription drugs
• C. Offers the best control over multiple-source pharmaceutical products
• D. Is the least expensive pricing system for the health plan to implement

Answer: A

NEW QUESTION 13

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 14

With respect to contractual provisions related to provider-patient communications, nonsolicitation clauses prohibit providers from

• A. Encouraging patients to switch from one health plan to another
• B. Disclosing confidential information about the health plan’s reimbursement structure
• C. Dispersing confidential financial information regarding the health plan
• D. Discussing alternative treatment plans with patients

Answer: A

NEW QUESTION 15

Partial capitation is one common approach to capitation. One typical characteristic of partial capitation is that it:

• A. Includes only primary care services
• B. Covers such services as immunizations and laboratory tests
• C. Can be used only if the provider's panel size is less than 50 providers
• D. Covers such services as cardiology and orthopedics

Answer: A

NEW QUESTION 16

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.
The following statement(s) can correctly be made about Gardenia’s establishment of the PPO and the staff model HMO in its new market:
* 1. When establishing its PPO network, Gardenia most likely initiated outcomes measurement tools and developed collaborative process improvement relationships with providers.
* 2. To avoid high overhead expenses in the early stages of market evelopment, Gardenia’s HMO most likely contracted with specialists and ancillary providers until the plan’s membership grew to a sufficient level to justify employing these specialists.

• A. Both 1 and 2
• B. Neither 1 nor 2
• C. 1 Only
• D. 2 Only

Answer: D

NEW QUESTION 17

If a third party is responsible for injuries to a plan member of the Hope Health Plan, then Hope has a contractual right to file a claim for the resulting healthcare costs against the third party. This contractual right to recovery from the third party is known as

• A. Subrogation
• B. Partial capitation
• C. Coordination of benefits
• D. Aremedy provision

Answer: A

NEW QUESTION 18
......