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NEW QUESTION 1
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
- A. Allow members direct access to OB/GYN services
- B. Allow members direct access to prescription drug services
- C. Provide access to Title X family-planning clinics
- D. Provide average office waiting times of no more than 30 minutes for appointments with plan providers
Answer: D
NEW QUESTION 2
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 3
The actual number of providers included in a provider network may be based on staffing ratios. Staffing ratios relate the number of
- A. Potential providers in a plan’s network to the number of individuals in the area to be served by the plan
- B. Providers in a plan’s network to the number of enrollees in the plan
- C. Providers outside a plan’s network to the number of providers in the plan’s network
- D. Support staff in a plan’s network to the number of medical practitioners in the plan’s network
Answer: B
NEW QUESTION 4
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 5
The actual number of providers included in a provider network can be based on staffing ratios. One true statement about staffing ratios is that, typically:
- A. A small health plan needs fewer physicians per 1,000 than does a large plan.
- B. A closely managed health plan requires fewer providers than does a loosely managedplan.
- C. Physician-to-enrollee ratios can be used directly only by network-within-a-network model HMOs.
- D. Medicare products require fewer providers than do employer-sponsored plans of the same size.
Answer: B
NEW QUESTION 6
Medicaid is a joint federal and state program that provides healthcare coverage for low- income, medically needy, and disabled individuals. Under the terms of this joint sponsorship, the
- A. Federal government is responsible for making all claim payments
- B. Federal government is responsible for determining the basic benefits that must be provided to eligible Medicaid beneficiaries
- C. State governments are responsible for setting minimum standards regarding eligibility, benefit coverage, and provider participation and reimbursement
- D. State governments are responsible for establishing overall regulation of the Medicaid program
Answer: B
NEW QUESTION 7
Dr. Janet Dubois is a radiologist who practices exclusively at the Rightway Healthcare Center. This information indicates that Dr. Dubois is employed by Rightway as
- A. An academic practitioner
- B. An independent practitioner
- C. Anetwork manager
- D. Ahospital-based specialist
Answer: D
NEW QUESTION 8
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 9
The following statements are about some of the issues surrounding the contractual responsibilities of health plans. Select the answer choice containing the correct statement.
- A. Typically, health plans are required to pay completed claims within 10 days of submission.
- B. Health plans typically are prohibited from examining the financial soundness of a self- funded employer plan that relies on the health plan to pay providers for services received by the plan’s members.
- C. Patient delivery is one of the most significant factors that health plans consider when determining whether provider services should be reimbursed on a capitated or fee-for- service (FFS) basis.
- D. Health plans require all providers to agree to an exclusive provider contract.
Answer: C
NEW QUESTION 10
Dr. Ahmad Shah and Dr. Shantelle Owen provide primary care services to Medicare+Choice enrollees of health plans under the following physician incentive plans:
Dr. Shah receives $40 per enrollee per month for providing primary care and an additional
$10 per enrollee per month if the cost of referral services falls below a specified level
Dr. Owen receives $30 per enrollee per month for providing primary care and an additional
$15 per enrollee per month if the cost of referral services falls below a specified level The use of a physician incentive plan creates substantial risk for
- A. Both D
- B. Shah and D
- C. Owen
- D. D
- E. Shah only
- F. D
- G. Owen only
- H. Neither D
- I. Shah nor D
- J. Owen
Answer: C
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
Reimbursement for prescription drugs and services in a third-party prescription drug plan typically follows one of two approaches: a reimbursement approach or a service approach. One true statement about these approaches is that:
- A. Payments under the reimbursement method typically are not subject to any copayment or deductible requirements
- B. Payments under the reimbursement approach are typically based on a structured reimbursement schedule rather than on usual, customary, and reasonable (UCR) charges
- C. Most major medical plans follow a service approach
- D. Most current health plan prescription drug plans are service plans
Answer: D
NEW QUESTION 13
If the Oconee Health Plan reimburses its specialty care physicians (SCPs) under a typical retainer method, then Oconee pays SCPs
- A. Aseparate amount for each service provided, and the payment amount is based solely on a resource-based relative value scale (RBRVS)
- B. Aspecified fee that remains the same regardless of how much or how little time or effort is spent on the medical service performed
- C. Aset amount each month, and Oconee reconciles its payment at periodic intervals on the basis of actual utilization
- D. Aset amount of cash equivalent to a defined time period’s expected reimbursable charges
Answer: C
NEW QUESTION 14
One type of fee schedule payment system assigns a weighted unit value for each medical procedure or service based on the cost and intensity of that service. Under this system, the unit values for procedural services are generally higher than the unit values for cognitive services. This system is known as a
- A. Wrap-around payment system
- B. Relative value scale (RVS) payment system
- C. Resource-based relative value scale (RBRVS) system
- D. Capped fee system
Answer: B
NEW QUESTION 15
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
- A. delegator, and Aegean is ultimately responsible for Brandon’s performance
- B. delegator, and Silhouette is ultimately responsible for Brandon’s performance
- C. subdelegate, and Aegean is ultimately responsible for Brandon’s performance
- D. subdelegate, and Silhouette is ultimately responsible for Brandon’s performance
Answer: C
NEW QUESTION 16
Promise, Inc., a corporation that specializes in cancer services, employs its physicians and support staff and provides facilities and ancillary services for cancer patients. Promise has contracted with the Cordelia Health Plan to provide all specialty services for Cordelia plan members who are undergoing cancer treatment. In return, Promise receives a capitated amount from Cordelia. Promise is an example of a type of specialty services organization known as a
- A. Specialty IPA
- B. Disease management company
- C. Single specialty management specialist
- D. Specialty network management company
Answer: B
NEW QUESTION 17
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