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NEW QUESTION 1
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement.
One important activity within the scope of network management is ensuring the quality of the health plan’s provider networks. A primary purpose of ________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan’s preestablished criteria for participation in the network.
- A. authorization
- B. provider relations
- C. credentialing
- D. utilization management
Answer: C
NEW QUESTION 2
The method of pharmaceutical reimbursement under which a plan member obtains prescription drugs from participating network pharmacies by presenting proper identification and paying a specified copayment is the
- A. Wholesale acquisition cost (WAC) approach
- B. Reimbursement approach
- C. Service approach
- D. Cognitive approach
Answer: C
NEW QUESTION 3
The following statements are about the inclusion of unified pharmacy benefits in health plan healthcare packages. Select the answer choice containing the correct statement.
- A. When pharmacy benefits management is incorporated into an health plan’s operations as a unified benefit, the health plan establishes pharmacy networks, but a pharmacy benefits management (PBM) company manages their operations.
- B. Under a unified pharmacy benefit, an health plan cannot use mail-order services to provide drugs to its members.
- C. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs typically give health plans more control over patient access to prescription drugs.
- D. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs make drug therapy interventions for plan members more difficult.
Answer: C
NEW QUESTION 4
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. A credentials verification organization (CVO) can be certified to verify certain pertinent credentialing information, including
- A. Liability claims histories of prospective providers
- B. Hospital privileges of prospective providers
- C. Malpractice insurance on prospective providers
- D. All of the above
Answer: D
NEW QUESTION 5
The Argyle Health Plan has contracted to obtain the services of the providers in the Column Medical Group, a faculty practice plan (FPP). The following statement(s) can correctly be made about this contract:
- A. Column most likely contracted with the legal group representing the FPP rather than with the individual physicians within the FPP.
- B. Column most likely will provide only highly specialized care to Argyle's plan members.
- C. Both A and B
- D. A only
- E. B only
- F. Neither A nor B
Answer: B
NEW QUESTION 6
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 7
The Omnibus Budget Reconciliation Act of 1986 (OBRA 1986) established the Programs of All-Inclusive Care for the Elderly (PACE). One characteristic of the PACE programs is that:
- A. They are available to United States citizens only after they reach age 65.
- B. They have an upper dollar limit.
- C. They receive a monthly capitation that is set at 100% of the Adjusted Average Per Capita Cost (AAPCC).
- D. PACE providers receive capitated payments only through the PACE agreement.
Answer: D
NEW QUESTION 8
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 9
From the following answer choices, choose the type of clause or provision described in this situation.
The provider contract between Dr. Olin Norquist and the Granite Health Plan specifies a time period for the party who has breached the contract to remedy the problem and avoid termination of the contract.
- A. Cure provision
- B. Hold-harmless provision
- C. Evergreen clause
- D. Exculpation clause
Answer: A
NEW QUESTION 10
Lakesha Frazier, a member of a health plan in a rural area, had been experiencing heart palpitations and shortness of breath. Ms. Frazier’s primary care provider (PCP) referred her to a local hospital for an electrocardiogram. The results of the electrocardiogram were transmitted for diagnosis via high-speed data transmission to a heart specialist in a city 500 miles away. This information indicates that the results of Ms. Frazier’s electrocardiogram were transmitted using a communications system known as
- A. Anarrow network
- B. An integrated healthcare delivery system
- C. Telemedicine
- D. Customized networking
Answer: C
NEW QUESTION 11
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 12
In order to evaluate and manage the performance of individual providers in its provider network, the Quorum Health Plan implemented a program that focuses on identifying the best and worst outcomes and utilization patterns of its providers. This program is also designed to develop and implement strategies such as treatment protocols and practice guidelines to improve the performance of Quorum's providers. This information indicates that Quorum implemented a program known as:
- A. An integrated delivery system (IDS)
- B. A coordinated care program
- C. Ostensible agency
- D. Continuous quality improvement (CQI)
Answer: D
NEW QUESTION 13
To protect providers against business losses, many health plan-provider contracts include carve-out provisions to help providers manage financial risk. The following statements are examples of such provisions:
The Apex Health Plan carves out immunizations from PCP capitations. Apex compensates PCPs for immunizations on a case rate basis.
The Bengal Health Plan carves out behavioral healthcare services from the scope of PCP services because these services require specialized knowledge and skills that most PCPs do not possess.
From the answer choices below, select the response that best identifies the types of carve- outs used by Apex and Bengal.
- A. Apex: disease-specific carve-out Bengal: specialty services carve-out
- B. Apex: disease-specific carve-out Bengal: specific-service carve-out
- C. Apex: specific-service carve-out Bengal: specialty services carve-out
- D. Apex: specific-service carve-out Bengal: disease-specific carve-out
Answer: C
NEW QUESTION 14
The NPDB specifies the entities that are eligible to request information from the data bank, as well as the conditions under which requests are allowed. In general, entities that are eligible to request information from the NPDB include
- A. medical malpractice insurers and the general public
- B. medical malpractice insurers and professional societies that are screening applicants for membership
- C. the general public and state licensing boards
- D. state licensing boards and professional societies that are screening applicants for membership
Answer: D
NEW QUESTION 15
A provider contract describes the responsibilities of each party to the contract. These responsibilities can be divided into provider responsibilities, health plan responsibilities, and mutual obligations. Mutual obligations typically include
- A. provisions for marketing the plan’s product
- B. payment arrangements between the plan and the provider
- C. verification of the plan’s eligibility to do business
- D. management of the contents of members’ medical records
Answer: B
NEW QUESTION 16
From the following answer choices, choose the term that best matches the description.
An integrated delivery system (IDS), which controls most providers in a particular specialty, agrees to provide that specialty service to a health plan only on thecondition that the health planagree to contract with the IDS for other services.
- A. Group boycott
- B. Horizontal division of territories
- C. Tying arrangements
- D. Concerted refusal to admit
Answer: C
NEW QUESTION 17
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