Network Management v4.0

Page:    1 / 14   
Total 202 questions Expand All

The following statements are about the specialist component of a provider panel. Select the answer choice containing the correct statement.

  • A. Ideally, a health plan should have every specialist category represented on its provider panel with appropriate geographic distribution.
  • B. Most specialist contracts do not ensure the providers adherence to UM policies set up by the health plan.
  • C. No-balance-billing clauses are not desirable in health plan contracts with specialists.
  • D. In geographic regions where there is a shortage of PCPs, a health plan is not permitted to contract with specialists to perform primary care services, even for patients with chronic conditions.


Answer : A

The Omni Health Plan is interested in expanding the specialty services it offers to its plan members and is considering contracting with the following providers of specialty services:
The Apex Company, a managed vision care organization (MVCO)
The Baxter Managed Behavioral Healthcare Organization (MBHO)
The Cheshire Dental Health Maintenance Organization (DHMO)
As part of its credentialing process, Omni would like to verify that each of these providers has met NCQAs accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for

  • A. Apex and Baxter only
  • B. Apex and Cheshire only
  • C. Baxter and Cheshire only
  • D. Baxter only


Answer : D

The Brice Health Plan submitted to Clarity Health Services a letter of intent indicating
Brices desire to delegate its demand management function to Clarity. One true statement about this letter of intent is that it

  • A. creates a legally binding relationship between Brice and Clarity
  • B. most likely contains a confidentiality clause committing Brice and Clarity to maintain the confidentiality of documents reviewed and exchanged in the process
  • C. prohibits Clarity from performing similar delegation activities for other health plans
  • D. most likely contains a detailed description of the functions that Brice will delegate to Clarity


Answer : B

Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in

  • A. Slower access to BH care for plan members
  • B. Increased collaboration between BH providers and PCPs
  • C. Fewer specialized BH services for plan members
  • D. Decreased continuity of BH care for plan members


Answer : D

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

Most health plan contracts provide an outline of the criteria that a healthcare service must meet in order to be considered medically necessary. Typically, in order for a healthcare service to be considered medically necessary, the service provided by a physician or other healthcare provider to identify and treat a members illness or injury must be

  • A. Consistent with the symptoms of diagnosis
  • B. Furnished in the least intensive type of medical care setting required by the members condition
  • C. In compliance with the standards of good medical practice
  • D. All of the above


Answer : D

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

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 Autumns PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumns dermatology services fund for the first quarter was $15,000. During the quarter, Autumns PCPs made 90 referrals, and 20 of these referrals were classified as complicated.
Autumns 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

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 providers 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

The following statements are about incentive programs used for providers. Select the answer choice containing the correct statement.

  • A. Risk pools based on aggregate provider performance eliminate problems associated with free riders.
  • B. A hospital bonus pool is usually split between the health plan and the PCPs.
  • C. Bonus pools based on the performance of specific providers are usually easier to administer than those based on the performance of the plan as a whole.
  • D. For providers, withhold arrangements eliminate the risk of losing base income.


Answer : B

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

An health plan enters into a professional services capitation arrangement whenever the health plan

  • A. Contracts with a medical group, clinic, or multispecialty IPA that assumes responsibility for the costs of all physician services related to a patients care
  • B. Pays individual specialists to provide only radiology services to all plan members
  • C. Transfers all financial risk for healthcare services to a provider organization and the provider, in turn, covers virtually all of a patients medical expenses
  • D. Contracts with a primary care provider to cover primary care services only


Answer : A

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

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 TRICAREs 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

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

Page:    1 / 14   
Total 202 questions Expand All

Talk to us!


Have any questions or issues ? Please dont hesitate to contact us