NEW QUESTION 1

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 2

State Medicaid agencies can contract with health plans through open contracting or selective contracting. One advantage of selective contracting is that it

• A. Allows enrollees to choose from among a greater variety of health plans
• B. Reduces the competition among health plans
• C. Increases the ability of new, local plans to participate in Medicaid programs
• D. Encourages the development of products that offer enhanced benefits and more effective approaches to health plans

Answer: D

NEW QUESTION 3

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 conforms to standards for prescribing controlled substances
• 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 4

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 5

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 6

The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:

• A. Must provide Medicare participants with standard HMO benefits, as well as with limited long-term care benefits
• B. Does not need as great a variety of provider types or as complex a reimbursement method as does a traditional HMO
• C. Receives a payment that is based on reasonable costs and reasonable charges
• D. Most likely provides fewer supportive services than does a traditional HMO, because one of Bruin's goals is to minimize the use of community-based care

Answer: A

NEW QUESTION 7

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 8

Jay Mercer is covered under his health plan’s vision care plan, which includes coverage for clinical eye care but not for routine eye care. Recently, Mr. Mercer had a general eye examination and got a prescription for corrective lenses. Mr. Mercer’s vision care plan will cover.

• A. both the general eye examination and the prescription for corrective lenses
• B. the general eye examination only
• C. the prescription for corrective lenses only
• D. neither the general eye examination nor the prescription for corrective lenses

Answer: D

NEW QUESTION 9

The Avignon Company discontinued its contract with a traditional indemnity insurer and contracted exclusively with the Minaret Health Plan to provide the sole healthcare plan to Avignon’s employees. By agreeing to an exclusive contract with Minaret, Avignon has entered into a type of healthcare contract known as

• A. a carrier guarantee arrangement
• B. open access
• C. total replacement coverage
• D. selective contract coverage

Answer: C

NEW QUESTION 10

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 11

The Walton Health Plan uses the fee-for-service pharmaceutical reimbursement approach known as the maximum allowable cost (MAC) method. If Walton’s MAC list specifies a cost of 8 cents per tablet for a particular drug but the participating pharmacy pays 10 cents per tablet for the drug, then Walton will be obligated to reimburse the pharmacy for

• A. 8 cents per tablet, but the pharmacy can bill the subscriber for the remaining 2 cents per tablet
• B. 8 cents per tablet, and the pharmacy cannot bill the subscriber for the remaining 2 cents per tablet
• C. 10 cents per tablet, but the pharmacy must refund the extra 2 cents per tablet to the subscriber
• D. 10 cents per tablet, and the pharmacy is not required to refund the extra 2 cents per tablet to the subscriber

Answer: B

NEW QUESTION 12

The following statements are about fee-for-service (FFS) payment systems. Select the answer choice containing the correct statement:

• A. A discounted fee-for-service (DFFS) system is usually easier for a health plan to administer than is a fee schedule system.
• B. A case rate payment system offers providers an incentive to take an active role in managing cost and utilization.
• C. One reason that health plans use a relative value scale (RVS) payment system is that RVS values for cognitive services have traditionally been higher than the values for procedural services.
• D. One reason that health plans use a resource-based relative value scale (RBRVS) is that this system includes weighted unit values for all types of procedures.

Answer: B

NEW QUESTION 13

Although a health plan is allowed to delegate many activities to outside sources, the National Committee for Quality Assurance (NCQA) has determined that some activities are not delegable.
These activities include

• A. evaluation of new medical technologies
• B. overseeing delegated medical records activities
• C. developing written statements of members’ rights and responsibilities
• D. all of the above

Answer: D

NEW QUESTION 14

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 15

A population’s demographic factors—such as income levels, age, gender, race, and ethnicity—can influence the design of provider networks serving that population. With respect to these demographic factors, it is correct to say that

• A. higher-income populations have a higher incidence of chronic illnesses than do lowerincome populations
• B. compared to other groups, young men are more likely to be attached to particular providers
• C. a population with a high proportion of women typically requires more providers than does a population that is predominantly male
• D. Health plans should not recognize, in either the design of networks or the evaluation of provider performance, racial and ethnic differences in the member population

Answer: C

NEW QUESTION 16

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 17

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 18

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.
The per diem reimbursement method will require Gladspell to pay Ellysium a

• A. Fixed rate for each day a plan member is treated in Ellysium’s subacute care facility
• B. Discounted charge for all subacute care services given by Ellysium
• C. Rate that varies depending on patient category
• D. Fixed rate per enrollee per month

Answer: A

NEW QUESTION 19
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