Question 1

One characteristic of the workers' compensation program is that:

Accepted Answer

A)  workers' compensation coverage is available to all employees, regardless of their eligibility for health insurance coverage 
B)  indemnity benefits currently account for less than 10% of all workers' compensation benefits 
C)  workers' compensation programs in most states require eligible employees to obtain medical treatment only from members of a provider network 
D)  workers' compensation programs include deductibles and coinsurance requirements 
A)  workers' compensation coverage is available to all employees, regardless of their eligibility for health insurance coverage 
B)  indemnity benefits currently account for less than 10% of all workers' compensation benefits 
C)  workers' compensation programs in most states require eligible employees to obtain medical treatment only from members of a provider network 
D)  workers' compensation programs include deductibles and coinsurance requirements

Question 2

The Edgewood Health Plan uses a combination of structural, process, outcomes, and customer satisfaction measures to evaluate its network providers' performance. Edgewood would correctly use outcomes measures to evaluate a provider's

Accepted Answer

A)  Compliance with specific regulatory or accrediting requirement 
B)  Appropriate use of specified procedures 
C)  Patient progress following treatment 
D)  Patient perceptions about how well the provider addresses medical problems 
A)  Compliance with specific regulatory or accrediting requirement 
B)  Appropriate use of specified procedures 
C)  Patient progress following treatment 
D)  Patient perceptions about how well the provider addresses medical problems

Question 3

The Zephyr Health Plan identifies members for whom subacute care might be an appropriate treatment option. The following individuals are members of Zephyr: Selena Tovar, an oncology patient who requires radiation oncology services, chemotherapy, and rehabilitation. Dwight Borg, who is in excellent health except that he currently has sinusitis. Timothy O'Shea, who is beginning his recovery from brain injuries caused by a stroke. Subacute care most likely could be an appropriate option for:

Accepted Answer

A)  Ms. Tovar, Mr. Borg, and Mr. O'Shea 
B)  Ms. Tovar and Mr. O'Shea only 
C)  Mr. O'Shea only 
D)  Mr. Borg only 
A)  Ms. Tovar, Mr. Borg, and Mr. O'Shea 
B)  Ms. Tovar and Mr. O'Shea only 
C)  Mr. O'Shea only 
D)  Mr. Borg only

Question 4

The Medicaid program subsidizes indigent care through payments to disproportionate share hospitals (DSHs). The Preamble Hospital is a DSH. As a DSH, Preamble most likely:

Accepted Answer

A)  Receives financial assistance from the federal government but not a state government. 
B)  Is at a higher risk of operating at a loss than are most other hospitals. 
C)  Receives no payments directly from Medicaid for services rendered but rather receives a portion of the capitation payment that Medicaid makes to the health plans with which Preamble contracts. 
D)  Is eligible for capitation rates that are significantly higher than the FFS average for all covered Medicaid services. 
A)  Receives financial assistance from the federal government but not a state government. 
B)  Is at a higher risk of operating at a loss than are most other hospitals. 
C)  Receives no payments directly from Medicaid for services rendered but rather receives a portion of the capitation payment that Medicaid makes to the health plans with which Preamble contracts. 
D)  Is eligible for capitation rates that are significantly higher than the FFS average for all covered Medicaid services.

Question 5

A provider group purchased from an insurer individual stop-loss coverage for primary and specialty care services with an $8,000 attachment point and 10% coinsurance. If the group's accrued cost for the primary and specialty care treatment of one patient is $10,000, then the amount that the insurer would be responsible for reimbursing the provider group for these costs is:

Accepted Answer

A)  $200 
B)  $1,000 
C)  $1,800 
D)  $9,000 
A)  $200 
B)  $1,000 
C)  $1,800 
D)  $9,000

Question 6

As part of the credentialing process, many health plans use the National Practitioner Data Bank (NPDB) to learn information about prospective members of a provider network. One true statement about the NPDB is that:

Accepted Answer

A)  It is maintained by the individual states 
B)  It primarily includes information about any censures, reprimands, or admonishments against any physicians who are licensed to practice medicine in the United States 
C)  The information in the NPDB is available to the general public 
D)  It was established to identify and discipline medical practitioners who act unprofessionally 
A)  It is maintained by the individual states 
B)  It primarily includes information about any censures, reprimands, or admonishments against any physicians who are licensed to practice medicine in the United States 
C)  The information in the NPDB is available to the general public 
D)  It was established to identify and discipline medical practitioners who act unprofessionally

Question 7

The Ventnor Health Plan requires the physicians in its provider network to be board certified. Ventnor has received requests to become a part of the network from the following specialists: Cheryl Stovall, who is currently in the process of completing a residency in her field of specialization. Thomas Kalil, who has completed a residency in his field of specialization and has passed a qualifying examination in that field within two years of completing his residency. Roger Todd, who has completed a residency in his field of specialization but has not passed a qualifying examination in that field. Ventnor's requirement of board certification is met by:

Accepted Answer

A)  Cheryl Stovall, Thomas Kalil, and Roger Todd. 
B)  Thomas Kalil and Roger Todd only. 
C)  Thomas Kalil only. 
D)  None of these individuals. 
A)  Cheryl Stovall, Thomas Kalil, and Roger Todd. 
B)  Thomas Kalil and Roger Todd only. 
C)  Thomas Kalil only. 
D)  None of these individuals.

Question 8

The Festival Health Plan is in the process of recruiting physicians for its provider network. Festival requires its network physicians to be board certified. The following individuals are provider applicants whose qualifications are being considered: Applicant 1 has completed his surgical residency, and he recently passed a qualifying examination in his field. Applicant 2 has completed her residency in dermatology, and she is scheduled to take qualifying examinations in the next Six months. Applicant 3 completed his residency in pediatric medicine six years ago, but he has not yet passed a qualifying examination in his field. With regard to these applicants, it can correctly be stated that only

Accepted Answer

A)  Applicants 1 and 2 are board certified 
B)  Applicants 2 and 3 are board certified 
C)  Applicant 1 is board certified 
D)  Applicant 3 is board certified 
A)  Applicants 1 and 2 are board certified 
B)  Applicants 2 and 3 are board certified 
C)  Applicant 1 is board certified 
D)  Applicant 3 is board certified

Question 9

The Enterprise Health Plan has indicated an interest in delegating its medical records review activities to the Teal Group and has forwarded a typical letter of intent to Teal. One true statement about this letter of intent is that it:

Accepted Answer

A)  Is a contract that creates a legally binding relationship between Enterprise and Teal 
B)  Cannot include a confidentiality clause 
C)  Serves as a delegation agreement between Enterprise and Teal 
D)  Outlines the delegation oversight process 
A)  Is a contract that creates a legally binding relationship between Enterprise and Teal 
B)  Cannot include a confidentiality clause 
C)  Serves as a delegation agreement between Enterprise and Teal 
D)  Outlines the delegation oversight process

Question 10

Assume that the national average cost per covered employee for PPO rental networks is $3 per member per month (PMPM) and that the average monthly healthcare premium PMPM is $300. This information indicates that, if the number of health plan members is 10,000, then the annual network rental cost to the health plan would be:

Accepted Answer

A)  $30,000 
B)  $360,000 
C)  $9,000,000 
D)  $12,000,000 
A)  $30,000 
B)  $360,000 
C)  $9,000,000 
D)  $12,000,000

Question 11

After HIPAA was enacted, Congress amended the law to include the Mental Health Parity Act (MHPA) of 1996, a federal requirement relating to mental health benefits. One true statement about the MHPA is that it

Accepted Answer

A)  requires all health plans to provide coverage for mental health services 
B)  requires health plans to carve out mental/behavioral healthcare from other services provided by the plans 
C)  allows health plans to require patients receiving mental health services to pay higher copayments than patients seeking treatment for physical illnesses 
D)  prohibits health plans that offer mental health benefits from applying more restrictive limits on coverage for mental illness than on coverage for physical illness 
A)  requires all health plans to provide coverage for mental health services 
B)  requires health plans to carve out mental/behavioral healthcare from other services provided by the plans 
C)  allows health plans to require patients receiving mental health services to pay higher copayments than patients seeking treatment for physical illnesses 
D)  prohibits health plans that offer mental health benefits from applying more restrictive limits on coverage for mental illness than on coverage for physical illness

Question 12

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

Accepted Answer

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 
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

Question 13

The Athena Medical Group has purchased from the Corinthian Insurance Company individual stop-loss insurance coverage for primary and specialty care services with a $5,000 attachment point and 10 percent coinsurance. One of Athena's patients accrued $8,000 of medical costs for primary and specialty care treatment. In this situation, Athena will be responsible for paying an amount equal to

Accepted Answer

A)  $300, and Corinthian is obligated to reimburse Athena in the amount of $2,700 
B)  $2,700, and Corinthian is obligated to reimburse Athena in the amount of $5,300 
C)  $5,300, and Corinthian is obligated to reimburse Athena in the amount of $2,700 
D)  $7,700, and Corinthian is obligated to reimburse Athena in the amount of $300 
A)  $300, and Corinthian is obligated to reimburse Athena in the amount of $2,700 
B)  $2,700, and Corinthian is obligated to reimburse Athena in the amount of $5,300 
C)  $5,300, and Corinthian is obligated to reimburse Athena in the amount of $2,700 
D)  $7,700, and Corinthian is obligated to reimburse Athena in the amount of $300

Question 14

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:

Accepted Answer

A)  An integrated delivery system (IDS) 
B)  A coordinated care program 
C)  Ostensible agency 
D)  Continuous quality improvement (CQI) 
A)  An integrated delivery system (IDS) 
B)  A coordinated care program 
C)  Ostensible agency 
D)  Continuous quality improvement (CQI)

Question 15

As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy CMS requirements regulating access to covered services. In order to ensure that its network provides adequate access, Brightwell must

Accepted Answer

A)  Allow enrollees to determine whether they will receive primary care from a physician, nurse practitioner, or other qualified network provider 
B)  Base a provider's participation in the network, reimbursement, and indemnification levels on the provider's license or certification 
C)  Define its service area according to community patterns of care 
D)  Require enrollees to obtain prior authorization for all emergency or urgently needed services 
A)  Allow enrollees to determine whether they will receive primary care from a physician, nurse practitioner, or other qualified network provider 
B)  Base a provider's participation in the network, reimbursement, and indemnification levels on the provider's license or certification 
C)  Define its service area according to community patterns of care 
D)  Require enrollees to obtain prior authorization for all emergency or urgently needed services

Question 16

The provider contract that the Danube Health Plan has with the Viola Home Health Services Organization states that Danube will use a typical flat rate reimbursement arrangement to compensate Viola for the skilled nursing services it provides to Danube's plan members. A portion of the contract's reimbursement schedule is shown below: Home Health Licensed Practical Nurse (LPN): $45 per visit or $90 per diem Home Health Registered Nurse (RN): $50 per visit or $110 per diem Last month, an LPN from Viola visited a Danube plan member and provided 1Ѕ hours of home healthcare, and an RN from Viola visited another Danube plan member and provided 7 hours of home healthcare. The following statement(s) can correctly be made about Danube's payment to Viola for these services:

Accepted Answer

A)  Danube most likely owes $90 for the LPN's skilled nursing services and $110 for the RN's skilled nursing services. 
B)  Danube's payment amount could be different from the amount called for in the reimbursement schedule if the level of care provided to one of these plan members was significantly different from the level of care normally provided by Viola's RNs and LPNs. 
C)  Both A and B 
D)  A only 
E)  B only
F) Neither A nor B 
A)  Danube most likely owes $90 for the LPN's skilled nursing services and $110 for the RN's skilled nursing services. 
B)  Danube's payment amount could be different from the amount called for in the reimbursement schedule if the level of care provided to one of these plan members was significantly different from the level of care normally provided by Viola's RNs and LPNs. 
C)  Both A and B 
D)  A only 
E)  B only
F) Neither A nor B

Question 17

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

Accepted Answer

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 
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

Question 18

A health plan has several options for delivering pharmacy services to its subscribers. Each option has potential advantages to a health plan. An advantage to a health plan of using:

Accepted Answer

A)  performance-based open networks is that they tend to increase participation in the pharmacy network. 
B)  closed networks is that they improve the health plan's ability to set standards and implement cost-control programs for pharmacy services. 
C)  customized networks is that they typically are inexpensive to operate. 
D)  open networks is that they tend to improve the health plan's ability to control pharmaceutical costs. 
A)  performance-based open networks is that they tend to increase participation in the pharmacy network. 
B)  closed networks is that they improve the health plan's ability to set standards and implement cost-control programs for pharmacy services. 
C)  customized networks is that they typically are inexpensive to operate. 
D)  open networks is that they tend to improve the health plan's ability to control pharmaceutical costs.

Question 19

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 NCQA's accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for

Accepted Answer

A)  Apex and Baxter only 
B)  Apex and Cheshire only 
C)  Baxter and Cheshire only 
D)  Baxter only 
A)  Apex and Baxter only 
B)  Apex and Cheshire only 
C)  Baxter and Cheshire only 
D)  Baxter only

Question 20

The following statements are about the organization of network management functions of health plans. Select the answer choice containing the correct response:

Accepted Answer

A)  Compared to a large health plan, a small health plan typically has more integration among its network management activities and less specialization of roles. 
B)  It is usually more efficient to have a large health plan's provider relations representatives located in the health plan's corporate headquarters rather than based in regional locations that are close to the provider offices the representatives cover. 
C)  An health plan's provider relations representatives are usually responsible for conducting an initial orientation of providers and educating providers about health plan developments, rather than recruiting and assisting with the selection of new providers. 
D)  In general, a health plan that uses a centralized approach for some of its network management activities should not use a decentralized approach for other network management activities. 
A)  Compared to a large health plan, a small health plan typically has more integration among its network management activities and less specialization of roles. 
B)  It is usually more efficient to have a large health plan's provider relations representatives located in the health plan's corporate headquarters rather than based in regional locations that are close to the provider offices the representatives cover. 
C)  An health plan's provider relations representatives are usually responsible for conducting an initial orientation of providers and educating providers about health plan developments, rather than recruiting and assisting with the selection of new providers. 
D)  In general, a health plan that uses a centralized approach for some of its network management activities should not use a decentralized approach for other network management activities.

One characteristic of the workers' compensation program is that:

The Edgewood Health Plan uses a combination of structural, process, outcomes, and customer satisfaction measures to evaluate its network providers' performance. Edgewood would correctly use outcomes measures to evaluate a provider's

The Medicaid program subsidizes indigent care through payments to disproportionate share hospitals (DSHs). The Preamble Hospital is a DSH. As a DSH, Preamble most likely:

As part of the credentialing process, many health plans use the National Practitioner Data Bank (NPDB) to learn information about prospective members of a provider network. One true statement about the NPDB is that:

The Enterprise Health Plan has indicated an interest in delegating its medical records review activities to the Teal Group and has forwarded a typical letter of intent to Teal. One true statement about this letter of intent is that it:

After HIPAA was enacted, Congress amended the law to include the Mental Health Parity Act (MHPA) of 1996, a federal requirement relating to mental health benefits. One true statement about the MHPA is that it

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

As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy CMS requirements regulating access to covered services. In order to ensure that its network provides adequate access, Brightwell must

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

A health plan has several options for delivering pharmacy services to its subscribers. Each option has potential advantages to a health plan. An advantage to a health plan of using:

The following statements are about the organization of network management functions of health plans. Select the answer choice containing the correct response:

AHM Medical Management

Governance and Regulation

Health Plan Finance and Risk Management

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Exam 4: Network Management

One characteristic of the workers' compensation program is that:

The Edgewood Health Plan uses a combination of structural, process, outcomes, and customer satisfaction measures to evaluate its network providers' performance. Edgewood would correctly use outcomes measures to evaluate a provider's

The Medicaid program subsidizes indigent care through payments to disproportionate share hospitals (DSHs). The Preamble Hospital is a DSH. As a DSH, Preamble most likely:

As part of the credentialing process, many health plans use the National Practitioner Data Bank (NPDB) to learn information about prospective members of a provider network. One true statement about the NPDB is that:

The Enterprise Health Plan has indicated an interest in delegating its medical records review activities to the Teal Group and has forwarded a typical letter of intent to Teal. One true statement about this letter of intent is that it:

After HIPAA was enacted, Congress amended the law to include the Mental Health Parity Act (MHPA) of 1996, a federal requirement relating to mental health benefits. One true statement about the MHPA is that it

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

As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy CMS requirements regulating access to covered services. In order to ensure that its network provides adequate access, Brightwell must

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

A health plan has several options for delivering pharmacy services to its subscribers. Each option has potential advantages to a health plan. An advantage to a health plan of using:

The following statements are about the organization of network management functions of health plans. Select the answer choice containing the correct response:

AHM Medical Management

Governance and Regulation

Health Plan Finance and Risk Management

Filters