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NEW QUESTION 1

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:

  • A. $200
  • B. $1,000
  • C. $1,800
  • D. $9,000

Answer: C

NEW QUESTION 2

The following statement(s) can correctly be made about contracting and reimbursement of specialty care physicians (SCPs):

  • A. Typically, a health plan should attempt to control utilization of SCPs before attempting to place these providers under a capitation arrangement.
  • B. Forms of specialty physician reimbursement used by health plans include a retainer and a bundled case rate.
  • C. Both A and B
  • D. A only
  • E. B only
  • F. Neither A nor B

Answer: A

NEW QUESTION 3

The Pine Health Plan has incorporated pharmacy benefits management into its operations to form a unified benefit. Potential advantages that Pine can receive from this action include:

  • A. the fact that unified benefits improve the quality of patient care and the value of pharmacy services to Pine's plan members
  • B. the fact that control over the formulary and network contracting can give Pine control over patient access to prescription drugs and to pharmacies
  • C. the fact that managing pharmacy benefits in-house gives Pine a better chance to meet customer needs by integrating pharmacy services into the plan's total benefits package
  • D. all of the above

Answer: D

NEW QUESTION 4

Martin Breslin, age 72 and permanently disabled, is classified as dually-eligible. This information indicates that Mr. Breslin qualifies for coverage by both

  • A. Medicare and private indemnity insurance, and Medicare provides primary coverage
  • B. Medicare and Medicaid, and Medicare provides primary coverage
  • C. Medicaid and private indemnity insurance, and Medicaid provides primary coverage
  • D. Medicare and Medicaid, and Medicaid provides primary coverage

Answer: B

NEW QUESTION 5

The Ross Health Plan compensates Dr. Cecile Sanderson on a FFS basis. In order to increase the level of reimbursement that she would receive from Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The services she actually provided represented an intermediate level of service. Dr. Sanderson’s action is an example of a type of false billing procedure known as

  • A. Cost shifting
  • B. Churning
  • C. Unbundling
  • D. Upcoding

Answer: D

NEW QUESTION 6

In most health plan pharmacy networks, the cost component of the reimbursement formula is based on the average wholesale price (AWP). One true statement about the AWP for prescription drugs is that

  • A. AWPs tend to vary widely from region to region of the United States
  • B. The AWP is often substantially higher than the actual price the pharmacy pays for prescription drugs
  • C. A health plan’s contracted reimbursement to a pharmacy for prescription drugs is typically the AWP plus a percentage, such as 5%
  • D. The AWP usually is lower than the estimated acquisition cost (EAC) for most prescription drugs

Answer: B

NEW QUESTION 7

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 reportincluded 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.
The report that helped Canyon determine how well Dr. Enberg met the health plan's standards is known as:

  • A. An encounter report
  • B. An external standards report
  • C. Aprovider profile
  • D. An access to care report

Answer: C

NEW QUESTION 8

The provider contract that Dr. Ted Dionne has with the Optimal Health Plan includes an arrangement that requires Dr. Dionne to notify Optimal if he contracts with another health plan at a rate that is lower than the rate offered to Optimal. Dr. Dionne must also offer this lower rate to Optimal. This information indicates that the provider contract includes a:

  • A. Most-favored-nation arrangement
  • B. Warranty arrangement
  • C. Locum tenens arrangement
  • D. Nesting arrangement

Answer: A

NEW QUESTION 9

The following statements describe two types of HMOs:
The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.
The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.
Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the NewnanGroup, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.
Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:
The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents per tablet for this drug.
The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.
The following statements can correctly be made about the reimbursement for Drugs A and B under the MAC pricing system:

  • A. Treble most likely is obligated to reimburse Manor 14 cents per tablet for Drug A.
  • B. Manor most likely is allowed to bill the subscriber 2 cents per tablet for Drug A.
  • C. Treble most likely is obligated to reimburse Manor 5 cents per tablet for Drug B.
  • D. All of the above statements are correct.

Answer: C

NEW QUESTION 10

From the following answer choices, choose the type of clause or provision described in this situation.
The Aviary Health Plan includes in its provider contracts a clause or provision that places the ultimate responsibility for an Aviary plan member’s medical care on the provider.

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

Answer: D

NEW QUESTION 11

Under the compensation arrangement that the Falcon Health Plan has with some of its providers, Falcon holds back 10% of the negotiated payments to these providers in order to offset or pay for any claims that exceed the budgeted costs for referral or hospital services. If the providers keep costs within the budgeted amount, Falcon distributes to them the entire amount of money held back. This way of motivating providers to control costs while providing high-quality, appropriate care is known as a:

  • A. Risk pool arrangement
  • B. Withhold arrangement
  • C. Cost-shifting arrangement
  • D. Bonus pool arrangement

Answer: B

NEW QUESTION 12

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's young patients receive appropriate immunizations at the right ages
  • 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 13

Health plans can often reduce workers’ compensation costs by incorporating 24-hour coverage into their workers’ compensations programs. Twenty-four-hour coverage reduces costs by

  • A. Maximizing the effects of cost shifting
  • B. Eliminating the need for utilization management
  • C. Requiring members to use separate points of entry for job-related and non-job related services
  • D. Combining administrative services for workers’ compensation and non-workers’ compensation healthcare and disability coverage

Answer: D

NEW QUESTION 14

The provider contract that Dr. Nick Mancini has with the Utopia Health Plan includes a clause that requires Utopia to reimburse Dr. Mancini on a fee-for-service (FFS) basis until 100 Utopia members have selected him as their primary care provider (PCP). At that time, Utopia will begin reimbursing him under a capitated arrangement. This clause in Dr. Mancini's provider contract is known as:

  • A. an antidisparagement clause
  • B. a low-enrollment guarantee clause
  • C. a retroactive enrollment changes clause
  • D. an eligibility guarantee clause

Answer: B

NEW QUESTION 15

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.

  • 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.

Answer: C

NEW QUESTION 16
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