Question 1

The Octagon Health Plan includes a typical indemnification clause in its provider contracts. The purpose of this clause is to require Octagon's network providers to

Accepted Answer

A)  Agree not to sue or file claims against an Octagon plan member for covered services 
B)  Reimburse Octagon for costs, expenses, and liabilities incurred by the health plan as a result of a provider's actions 
C)  Maintain the confidentiality of the health plan's proprietary information 
D)  Agree to accept Octagon's payment as payment in full and not to bill members for anything other than contracted copayments, coinsurance, or deductibles 
A)  Agree not to sue or file claims against an Octagon plan member for covered services 
B)  Reimburse Octagon for costs, expenses, and liabilities incurred by the health plan as a result of a provider's actions 
C)  Maintain the confidentiality of the health plan's proprietary information 
D)  Agree to accept Octagon's payment as payment in full and not to bill members for anything other than contracted copayments, coinsurance, or deductibles

Question 2

The following statements are about Medicaid health plan entities. Select the answer choice containing the correct statement:

Accepted Answer

A)  To keep Medicaid enrollment costs as low as possible, states typically prohibit the use of third- party entities known as enrollment brokers to handle the recruitment and enrollment of Medicaid recipients in health plan plans 
B)  Primary care case managers (PCCMs) are individuals who contract with a state's Medicaid agency to provide primary care services mainly to urban areas. 
C)  Typically, Medicaid beneficiaries must be given a choice between at least two health plan entities. 
D)  Medicaid health plan entities are responsible for providing primary coverage for all dually- eligible beneficiaries. 
A)  To keep Medicaid enrollment costs as low as possible, states typically prohibit the use of third- party entities known as enrollment brokers to handle the recruitment and enrollment of Medicaid recipients in health plan plans 
B)  Primary care case managers (PCCMs) are individuals who contract with a state's Medicaid agency to provide primary care services mainly to urban areas. 
C)  Typically, Medicaid beneficiaries must be given a choice between at least two health plan entities. 
D)  Medicaid health plan entities are responsible for providing primary coverage for all dually- eligible beneficiaries.

Question 3

The Foxfire Health Plan, which has 20,000 members, contracts with dermatologists on a contact capitation basis. The contact capitation arrangement has the following features: Foxfire distributes the money in the contact capitation fund once each quarter and the distribution is based on the point totals accumulated by each dermatologist. Foxfire's per member per month (PMPM) capitation for dermatology services is $1. The dermatologist receives 1 point for each new referral that is not classified as a complicated referral and 1.5 points for each new referral that is classified as complicated. During the first quarter, Foxfire's PCPs made 450 referrals to dermatologists and 100 of these referrals were classified as complicated. One dermatologist, Dr. Shareef Rashad, received 42 of these referrals; 6 of his referrals were classified as complicated. Statements that can correctly be made about Foxfire's contact capitation arrangement include:

Accepted Answer

A)  that the value of each referral point for the first quarter was $120 
B)  that the value of Foxfire's contact capitation fund for dermatologists for the first quarter was $20,000 
C)  that the payment that Foxfire owed Dr. Rashad for the first quarter was $6,120 
D)  all of the above 
A)  that the value of each referral point for the first quarter was $120 
B)  that the value of Foxfire's contact capitation fund for dermatologists for the first quarter was $20,000 
C)  that the payment that Foxfire owed Dr. Rashad for the first quarter was $6,120 
D)  all of the above

Question 4

In developing a provider network in an large city with a high concentration of young families, the Gypsum Health Plan has set goals focused on the needs of that particular market. The following statements are about this situation. Three of the statements are true, and one of the statements is false. Select the answer choice that contains the FALSE statement.

Accepted Answer

A)  Gypsum should attempt to recruit providers who offer extended office hours. 
B)  Gypsum can use the cost-effectiveness of its own existing networks as a benchmark for its cost-savings goals in this market. 
C)  Gypsum will most likely attempt to contract with HMOs. 
D)  Gypsum most likely should set lower cost-savings goals in this market than it would in a rural market with few young families. 
A)  Gypsum should attempt to recruit providers who offer extended office hours. 
B)  Gypsum can use the cost-effectiveness of its own existing networks as a benchmark for its cost-savings goals in this market. 
C)  Gypsum will most likely attempt to contract with HMOs. 
D)  Gypsum most likely should set lower cost-savings goals in this market than it would in a rural market with few young families.

Question 5

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. If Gladspell's per diem contract with Ellysium is typical, then the per diem payment will cover such medical costs as

Accepted Answer

A)  Laboratory tests 
B)  Respiratory therapy 
C)  Semiprivate room and board 
D)  Radiology services 
A)  Laboratory tests 
B)  Respiratory therapy 
C)  Semiprivate room and board 
D)  Radiology services

Question 6

The provider contract that Dr. Bijay Patel has with the Arbor Health Plan includes a no-balance-billing clause. The purpose of this clause is to:

Accepted Answer

A)  prohibit Dr. Patel from collecting payments from Arbor plan members for medical services that he provided them, even if the services are explicitly excluded from the benefit plan 
B)  allow Dr. Patel to bill patients for services only if the services are considered to be medically necessary 
C)  establish the guidelines used to determine if Arbor is the primary payor of benefits in a situation in which an Arbor plan member is covered by more than one health plan 
D)  require Dr. Patel to accept Arbor's payment as payment in full for medical services that he provides to Arbor plan members 
A)  prohibit Dr. Patel from collecting payments from Arbor plan members for medical services that he provided them, even if the services are explicitly excluded from the benefit plan 
B)  allow Dr. Patel to bill patients for services only if the services are considered to be medically necessary 
C)  establish the guidelines used to determine if Arbor is the primary payor of benefits in a situation in which an Arbor plan member is covered by more than one health plan 
D)  require Dr. Patel to accept Arbor's payment as payment in full for medical services that he provides to Arbor plan members

Question 7

The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes. The comparative method of evaluation that Azure uses to identify and implement the practices that lead to the best outcomes is known as

Accepted Answer

A)  Case mix analysis 
B)  Outcomes research 
C)  Benchmarking 
D)  Provider profiling 
A)  Case mix analysis 
B)  Outcomes research 
C)  Benchmarking 
D)  Provider profiling

Question 8

From the following answer choices, choose the type of clause or provision described in this situation. The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.

Accepted Answer

A)  Cure provision 
B)  Hold-harmless provision 
C)  Evergreen clause 
D)  Exculpation clause 
A)  Cure provision 
B)  Hold-harmless provision 
C)  Evergreen clause 
D)  Exculpation clause

Question 9

An health plan's contract negotiation team consists of several skilled individuals from different areas. At least one of the members is responsible for evaluating the wording of specific clauses to ensure that the health plan's rights are protected, as well as to ensure that the contract is in compliance with state and federal regulation. By profession, this member of the contract negotiation team is typically

Accepted Answer

A)  Amedical director 
B)  An attorney 
C)  Afinancial manager 
D)  Aclaims manager 
A)  Amedical director 
B)  An attorney 
C)  Afinancial manager 
D)  Aclaims manager

Question 10

Although ambulatory payment classifications (APCs) bear some resemblance to diagnosis-related groups (DRGs), there are significant differences between APCs and DRGs. One of these differences is that APCs:

Accepted Answer

A)  typically allow for the assignment of multiple classifications for an outpatient visit 
B)  always apply to a patient's entire hospital stay 
C)  typically serve as a payment system for inpatient services 
D)  typically include reimbursements for professional fees 
A)  typically allow for the assignment of multiple classifications for an outpatient visit 
B)  always apply to a patient's entire hospital stay 
C)  typically serve as a payment system for inpatient services 
D)  typically include reimbursements for professional fees

Question 11

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. If the Ellysium subacute care unit is typical of most hospital-based subacute skilled nursing units, then this unit could be used for patients who no longer need to be in the hospital's acute care unit but who still require

Accepted Answer

A)  Daily medical care and monitoring 
B)  Regular rehabilitative therapy 
C)  Respiratory therapy 
D)  All of the above 
A)  Daily medical care and monitoring 
B)  Regular rehabilitative therapy 
C)  Respiratory therapy 
D)  All of the above

Question 12

The following statements are about the delegation of network management activities from a health plan to another party. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:

Accepted Answer

A)  The NCQA requires a health plan to conduct all delegation oversight functions rather than delegating the responsibility for oversight to another entity. 
B)  Credentialing and UM activities are the most frequently delegated functions, whereas delegation is less common for quality management (QM) and preventive health services. 
C)  One reason that a health plan may choose to delegate a function is because the health plan's staff seeks external expertise for the delegated activity. 
D)  When the health plan delegates authority for a function, it transfers the power to conduct the function on a day-to-day basis, as well as the ultimate accountability for the function. 
A)  The NCQA requires a health plan to conduct all delegation oversight functions rather than delegating the responsibility for oversight to another entity. 
B)  Credentialing and UM activities are the most frequently delegated functions, whereas delegation is less common for quality management (QM) and preventive health services. 
C)  One reason that a health plan may choose to delegate a function is because the health plan's staff seeks external expertise for the delegated activity. 
D)  When the health plan delegates authority for a function, it transfers the power to conduct the function on a day-to-day basis, as well as the ultimate accountability for the function.

Question 13

Stop-loss insurance is designed to protect physicians who face substantial financial risk as a result of physician incentive plans. Medicare + Choice health plans must ensure that a physician has adequate stop-loss protection if the

Accepted Answer

A)  physician has a patient panel that exceeds 25,000 patients 
B)  physician receives a bonus that is based solely on quality of care, patient satisfaction, or physician participation 
C)  difference between the physician's maximum potential payments and his or her minimum potential payments is less than 25% of the maximum potential payments 
D)  physician is subject to a withhold that is greater than 25% of his or her potential payments 
A)  physician has a patient panel that exceeds 25,000 patients 
B)  physician receives a bonus that is based solely on quality of care, patient satisfaction, or physician participation 
C)  difference between the physician's maximum potential payments and his or her minimum potential payments is less than 25% of the maximum potential payments 
D)  physician is subject to a withhold that is greater than 25% of his or her potential payments

Question 14

The following statements are about the responsibilities that providers are expected to assume under most provider contracts with health plans. Select the answer choice containing the correct statement.

Accepted Answer

A)  All health plans now include in their provider contracts a statement that explicitly places responsibility for the medical care of plan members on the health plan rather than on the provider. 
B)  According to the wording of most provider contracts, the responsibility of providers to deliver medical services to a plan member is not contingent upon the provider's receipt of information regarding the member's eligibility for these services. 
C)  Most health plans include in their provider contracts a clause which requires providers to maintain open communication with plan members regarding appropriate treatment plans, even if the services are not covered by the member's health plan. 
D)  Most provider contracts require participating providers to discuss health plan payment arrangements with patients who are covered by the plan. 
A)  All health plans now include in their provider contracts a statement that explicitly places responsibility for the medical care of plan members on the health plan rather than on the provider. 
B)  According to the wording of most provider contracts, the responsibility of providers to deliver medical services to a plan member is not contingent upon the provider's receipt of information regarding the member's eligibility for these services. 
C)  Most health plans include in their provider contracts a clause which requires providers to maintain open communication with plan members regarding appropriate treatment plans, even if the services are not covered by the member's health plan. 
D)  Most provider contracts require participating providers to discuss health plan payment arrangements with patients who are covered by the plan.

Question 15

The following statements are about network management for behavioral healthcare (BH). Three of these statements are true and one statement is false. Select the answer choice containing the FALSE statement.

Accepted Answer

A)  Two measures of BH quality are patient satisfaction and clinical outcomes assessments. 
B)  For a health plan, one argument in favor of contracting with a managed behavioral healthcare organization (MBHO) is that the health plan's members can gain faster access to BH care. 
C)  In their contracts with health plans, managed behavioral healthcare organizations (MBHOs) usually receive delegated authority for network development and management. 
D)  Health plans generally compensate managed behavioral healthcare organizations (MBHOs) on an FFS basis. 
A)  Two measures of BH quality are patient satisfaction and clinical outcomes assessments. 
B)  For a health plan, one argument in favor of contracting with a managed behavioral healthcare organization (MBHO) is that the health plan's members can gain faster access to BH care. 
C)  In their contracts with health plans, managed behavioral healthcare organizations (MBHOs) usually receive delegated authority for network development and management. 
D)  Health plans generally compensate managed behavioral healthcare organizations (MBHOs) on an FFS basis.

Question 16

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

Accepted Answer

A)  Wrap-around payment system 
B)  Relative value scale (RVS) payment system 
C)  Resource-based relative value scale (RBRVS) system 
D)  Capped fee system 
A)  Wrap-around payment system 
B)  Relative value scale (RVS) payment system 
C)  Resource-based relative value scale (RBRVS) system 
D)  Capped fee system

Question 17

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO. The following statement(s) can correctly be made about Gardenia's establishment of the PPO and the staff model HMO in its new market: 1. When establishing its PPO network, Gardenia most likely initiated outcomes measurement tools and developed collaborative process improvement relationships with providers. 2. To avoid high overhead expenses in the early stages of market evelopment, Gardenia's HMO most likely contracted with specialists and ancillary providers until the plan's membership grew to a sufficient level to justify employing these specialists.

Accepted Answer

A)  Both 1 and 2 
B)  Neither 1 nor 2 
C)  1 Only 
D)  2 Only 
A)  Both 1 and 2 
B)  Neither 1 nor 2 
C)  1 Only 
D)  2 Only

Question 18

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

Accepted Answer

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 provider's 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. 
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 provider's 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.

Question 19

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

Accepted Answer

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 
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

Question 20

With regard to the laws and regulations on access and adequacy of provider networks, it can correctly be stated that:

Accepted Answer

A)  most access and adequacy guidelines relate to preferred provider organizations (PPOs) or managed indemnity products 
B)  corporate practice of medicine laws require staff model HMOs to hire physicians directly, even if the physicians do not own the HMO 
C)  any willing provider laws prevent a health plan from making exclusive or semi-exclusive arrangements with a provider or a group of providers 
D)  the NAIC Managed Care Plan Network Adequacy Model Act requires states to use provider- enrollee ratios as the sole measure of network adequacy 
A)  most access and adequacy guidelines relate to preferred provider organizations (PPOs) or managed indemnity products 
B)  corporate practice of medicine laws require staff model HMOs to hire physicians directly, even if the physicians do not own the HMO 
C)  any willing provider laws prevent a health plan from making exclusive or semi-exclusive arrangements with a provider or a group of providers 
D)  the NAIC Managed Care Plan Network Adequacy Model Act requires states to use provider- enrollee ratios as the sole measure of network adequacy

The Octagon Health Plan includes a typical indemnification clause in its provider contracts. The purpose of this clause is to require Octagon's network providers to

The following statements are about Medicaid health plan entities. Select the answer choice containing the correct statement:

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. If Gladspell's per diem contract with Ellysium is typical, then the per diem payment will cover such medical costs as

The provider contract that Dr. Bijay Patel has with the Arbor Health Plan includes a no-balance-billing clause. The purpose of this clause is to:

From the following answer choices, choose the type of clause or provision described in this situation. The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.

Although ambulatory payment classifications (APCs) bear some resemblance to diagnosis-related groups (DRGs), there are significant differences between APCs and DRGs. One of these differences is that APCs:

The following statements are about the delegation of network management activities from a health plan to another party. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:

Stop-loss insurance is designed to protect physicians who face substantial financial risk as a result of physician incentive plans. Medicare + Choice health plans must ensure that a physician has adequate stop-loss protection if the

The following statements are about the responsibilities that providers are expected to assume under most provider contracts with health plans. Select the answer choice containing the correct statement.

The following statements are about network management for behavioral healthcare (BH). Three of these statements are true and one statement is false. Select the answer choice containing the FALSE statement.

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

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

With regard to the laws and regulations on access and adequacy of provider networks, it can correctly be stated that:

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Exam 4: Network Management

The Octagon Health Plan includes a typical indemnification clause in its provider contracts. The purpose of this clause is to require Octagon's network providers to

The following statements are about Medicaid health plan entities. Select the answer choice containing the correct statement:

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. If Gladspell's per diem contract with Ellysium is typical, then the per diem payment will cover such medical costs as

The provider contract that Dr. Bijay Patel has with the Arbor Health Plan includes a no-balance-billing clause. The purpose of this clause is to:

From the following answer choices, choose the type of clause or provision described in this situation. The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.

Although ambulatory payment classifications (APCs) bear some resemblance to diagnosis-related groups (DRGs), there are significant differences between APCs and DRGs. One of these differences is that APCs:

The following statements are about the delegation of network management activities from a health plan to another party. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:

Stop-loss insurance is designed to protect physicians who face substantial financial risk as a result of physician incentive plans. Medicare + Choice health plans must ensure that a physician has adequate stop-loss protection if the

The following statements are about the responsibilities that providers are expected to assume under most provider contracts with health plans. Select the answer choice containing the correct statement.

The following statements are about network management for behavioral healthcare (BH). Three of these statements are true and one statement is false. Select the answer choice containing the FALSE statement.

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

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

With regard to the laws and regulations on access and adequacy of provider networks, it can correctly be stated that:

AHM Medical Management

Governance and Regulation

Health Plan Finance and Risk Management

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