AHM 530 - Tests

Assignment 1: The Network Management Function
Reading 1A: The Role of Network Management in a Health Plan Organization
• Explain the meaning of network management and list some of the activities that are typically included in this
function
• Describe the role of a network management director, a contracting specialist, and a provider relations representative
in network management
• Define profiling and explain its significance in network management
• Describe some training and support approaches that health plan organizations (health plans) use to improve the
performance of network management staff
• Explain the relationship between network management and medical management, risk management, member
services, and claims administration
Instructions:
1. Select or enter the best answer for each of the 5 questions.

2. Answer all the questions. Remember to scroll down if necessary.
Complete the Test

3. Click Complete the Test to score your answers and view a report.
Go to
1. By definition, a measure of the extent to which a health plan member can
question
obtain necessary medical services in a timely manner is known as 2.
network management
quality
cost-effectiveness
accessibility
2. Decide whether the following statement is true or false:
The organizational structure of a health plan’s network management function Go to

often depends on the size and geographic scope of the health plan. With question
3.
respect to the size of a health plan, it is correct to say that smaller health
plans typically have less integration and more specialization of roles than do
larger health plans.
True
False
3. The following paragraph contains an incomplete statement. Select the

answer choice containing the term that correctly completes the statement.
Go to
One important activity within the scope of network management is ensuring question
the quality of the health plan’s provider networks. A primary purpose of 4.
__________________ is to review the clinical competence of a provider in
order to determine whether the provider meets the health plan’s
preestablished criteria for participation in the network.
authorization
provider relations
credentialing
utilization management
Go to
4. One important aspect of network management is profiling, or provider
question
profiling. Profiling is most often used to 5.
measure the overall performance of providers who are already
participants in the network
assess a provider’s overall satisfaction with a plan’s service protocols and
other operational areas
verify a prospective provider’s professional licenses, certifications, and
training
familiarize a provider with a plan’s procedures for authorizations and
referrals
5. Network managers rely on a health plan’s claims administration

department for much of the information needed to manage the performance
Back to
of providers who are not under a capitation arrangement. Examining claims Top
submitted to a health plan’s claims administration department enables the
health plan to
determine the number of healthcare services delivered to plan members
monitor the types of services provided by the health plan’s entire
provider network
evaluate providers’ practice patterns and compliance with the health
plan’s procedures for the delivery of care
all of the above
>---------- End of the Test ----------<
1 D
2 B
3 C
4 A
5 D
Reading 1B: Environmental Considerations for Network Management
• Understand the numerous legislative and regulatory requirements that affect network management
• Identify the expectations of purchasers and consumers with respect to network management
• Describe how health plans balance complex and sometimes competing interests and requirements in managing
provider panels
Instructions:

Complete the Test

1. The Avignon Company discontinued its contract with a traditional
indemnity insurer and contracted exclusively with the Minaret Health Plan to Go to
provide the sole healthcare plan to Avignon’s employees. By agreeing to an question
exclusive contract with Minaret, Avignon has entered into a type of 2.
healthcare contract known as
a carrier guarantee arrangement
open access
total replacement coverage
selective contract coverage
2. Federal laws—including the Ethics in Patient Referrals Act, the Health

Maintenance Organization (HMO) Act of 1973, the Employee Retirement
Income Security Act (ERISA), and the Federal Trade Commission Act—have
impacted the ways that health plans conduct business. For instance, the
Mosaic Health Plan must comply with the following federal laws in order to
operate:
Go to
Regulation 1: Mosaic must establish a mandated grievance resolution
question
mechanism, including a method for members to address grievances with 3.
network providers.
Regulation 2: Mosaic must not allow its providers to refer Medicare and
Medicaid patients toentities in which they have a financial or ownership
interest.
From the answer choices below, select the response that correctly identifies
the federal legislation on which Regulation 1 and Regulation 2 are based.
Regulation 1 - The Ethics in Patient Referrals Act Regulation 2 -
The HMO Act of 1973
Regulation 1 - The HMO Act of 1973 Regulation 2 - The Ethics in
Patient Referrals Act
Regulation 1 - ERISA Regulation 2 - The Federal Trade Commission
Act
Regulation 1 - The Federal Trade Commission Act Regulation 2 -
ERISA
3. In 1996, Congress passed the Health Insurance Portability and

Go to
Accountability Act (HIPAA), which increased the continuity and portability of
question
health insurance coverage. One statement that can correctly be made about 4.
HIPAA is that it
applies to group health insurance plans only
limits the length of a health plan’s pre-existing condition exclusion period
for a previously covered individual to a maximum of six months after
enrollment.
guarantees access to healthcare coverage for small businesses and
previously covered individuals who meet specified eligibility
requirements.
guarantees renewability of group and individual health coverage,
provided the insureds are still in good health
4. After HIPAA was enacted, Congress amended the law to include the Mental Go to
Health Parity Act (MHPA) of 1996, a federal requirement relating to mental question
health benefits. One true statement about the MHPA is that it 5.
requires all health plans to provide coverage for mental health services
requires health plans to carve out mental/behavioral healthcare from
other services provided by the plans
allows health plans to require patients receiving mental health services
to pay higher copayments than patients seeking treatment for physical
illnesses
prohibits health plans that offer mental health benefits from applying
more restrictive limits on coverage for mental illness than on coverage
for physical illness
5. From the following answer choices, choose the term that best matches the
description.
Go to
An integrated delivery system (IDS), which controls most providers in a question
6.
particular specialty, agrees to provide that specialty service to a health plan
only on the condition that the health plan agree to contract with the IDS for
other services.
Group boycott
Horizontal division of territories
Tying arrangements
Concerted refusal to admit
6. From the following answer choices, choose the term that best matches the Go to
question
description.
7.
Members of a physician-hospital organization (PHO) denied membership to a

physician solely because the physician has admitting privileges at a
competing hospital.
Group boycott
Horizontal division of territories
Tying arrangements
Concerted refusal to admit
7. Some states have enacted any willing provider laws. From the perspective Go to
of the health plan industry, one drawback of any willing provider laws is that question
they often result in a reduction of a plan’s 8.
premium rates
ability to monitor utilization
number of primary care providers (PCPs)
number of specialists and ancillary providers
8. 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.
Go to
In most states, a health plan can be held responsible for a provider’s question
9.
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).
vicarious liability / employees of the health plan
vicarious liability / independent contractors
risk sharing / employees of the health plan
risk sharing / independent contractors
9. The National Committee for Quality Assurance (NCQA) has integrated

Go to
accreditation with Health Employer Data and Information Set (HEDIS)
question
measures into a program called Accreditation ’99. One statement that can 10.
correctly be made about these accreditation standards is that
Health plans are required by law to report HEDIS results to NCQA
HEDIS restricts its reporting criteria to a narrow group of quantitative
performance measures, while NCQA includes a broad range of qualitative
performance measures
private employer groups purchasing health care coverage increasingly
require both NCQA accreditation and HEDIS reporting
HEDIS includes measures of a health plan’s effectiveness of care rather
than its cost of care
10. The National Association of Insurance Commissioners (NAIC) Managed
Go to
Care Plan Network Adequacy Model Act defines specific adequacy and
question
accessibility standards that health plans must meet. In addition, the Model 11.
Act requires health plans to
hold plan members responsible for unreimbursed charges or unpaid
claims
allow providers to develop their own standards of care
adhere to specified disclosure requirements related to provider contract
termination
file written access plans and sample contracts with the Centers for
Medicaid and Medicare Services (CMS)
11. The following statement(s) can correctly be made about the TRICARE
managed healthcare program of the U.S. Department of Defense.
Back to
1. Active-duty military personnel are automatically enrolled in TRICARE’s Top
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).
Both 1 and 2
1 only
2 only
Neither 1 nor 2
>---------- End of the Test ----------<
1 C
2 B
3 C
4 D
5 C
6 A
7 B
8 B
9 C
10 C
11 A
Assignment 2: Strategies for Network Development and Management
Reading 2A: Analysis of Market and health plan Needs
• Explain how the presence of provider organizations and the level of market maturity affect network strategies
• Explain how a health plan can use a competitive analysis to determine the size of the network
• Describe some differences between network needs for large employers and needs for small employers
• Describe some of the challenges that health plans face when developing networks in rural areas
• List several different areas for which a health plan should establish goals before beginning to develop or revise a
provider network
Instructions:

Complete the Test

1. For this question, if answer choices (A) through C) are all correct, select
answer choice (D). Otherwise, select the one correct answer choice.
Go to
question
Understanding the level of health plan penetration in a particular market can 2.
help a health plan determine which products are most appropriate for that
market. Indicators of a mature health plan market include
a reduction in the rate of growth in health plan premium levels
a reduction in the level of outcomes management and improvement
an increase in the rate of inpatient hospital utilization
all of the above
2. The Holiday Health Plan is preparing to enter a new market. In order to

determine the optimal size of its provider panel in the new market, Holiday is
conducting a competitive analysis of provider networks of the market’s
existing health plans. Consider whether, in conducting its competitive
analysis, Holiday should seek answers to the following questions:
Question 1: What are the cost-containment strategies of the health plans Go to

with increasing market shares? question
Question 2: What are the premium strategies of the health plans with large 3.
market shares?
Question 3: What are the characteristics of health plans that are losing
market share?
In its competitive analysis, Holiday should most likely obtain answers to

questions
1, 2, and 3
1 and 2 only
1 and 3 only
2 and 3 only
3. The sizes of the businesses in a market affect the types of health programs
Go to
that are likely to be purchased. Compared to smaller employers (those with
question
fewer than 100 employees), larger employers (those with more than 1,000 4.
employees) are
more likely to contract with indemnity health plans
more likely to offer their employees a choice in health plans
less likely to contract with health plans
less likely to require a wide variety of benefits
4. Provider panels can be either narrow or broad. Compared to a similarly Go to

sized health plan that uses a broad provider panel, a health plan that uses a question
narrow provider panel most likely can expect to 5.
experience higher contracting costs

encounter increased difficulty in utilization management
have to charge higher health plan premiums
experience lower provider relations costs
5. The following statements are about factors that health plans should
Go to
consider as they develop provider networks in rural and urban markets.
question
Three of the statements are true, and one of the statements is false. Select 6.
the answer choice that contains the FALSE statement.
Compared to providers in urban areas, providers in rural areas are less
likely to offer discounts to health plans in exchange for directed patient
volume.
In urban areas, limiting the number of specialists on a panel usually
affects the network’s market appeal more than does limiting the number
of primary care physicians.
The greatest opportunity to create competition in rural areas is among
the specialty providers in other nearby communities.
Typically, hospital contracting is easier in urban areas than in rural
areas.
6. Lakesha Frazier, a member of a health plan in a rural area, had been

experiencing heart palpitations and shortness of breath. Ms. Frazier’s primary
care provider (PCP) referred her to a local hospital for an electrocardiogram. Go to
The results of the electrocardiogram were transmitted for diagnosis via high- question
speed data transmission to a heart specialist in a city 500 miles away. This 7.
information indicates that the results of Ms. Frazier’s electrocardiogram were
transmitted using a communications system known as
a narrow network
an integrated healthcare delivery system
telemedicine
customized networking
7. A population’s demographic factors—such as income levels, age, gender,

Go to
race, and ethnicity—can influence the design of provider networks serving
question
that population. With respect to these demographic factors, it is correct to 8.
say that
higher-income populations have a higher incidence of chronic illnesses
than do lowerincome populations
compared to other groups, young men are more likely to be attached to
particular providers
a population with a high proportion of women typically requires more
providers than does a population that is predominantly male
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
8. 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
Back to
needs of that particular market. The following statements are about this Top
situation. Three of the statements are true, and one of the statements is
false. Select the answer choice that contains the FALSE statement.
Gypsum should attempt to recruit providers who offer extended office
hours.
Gypsum can use the cost-effectiveness of its own existing networks as a
benchmark for its cost-savings goals in this market.
Gypsum will most likely attempt to contract with HMOs.
Gypsum most likely should set lower cost-savings goals in this market
than it would in a rural market with few young families.
>---------- End of the Test ----------<
1 A
2 A
3 B
4 D
5 B
6 C
7 C
8 D
Reading 2B: Considerations for the Structure, Composition, and Size of the Network
• Explain how a network-within-a-network approach can benefit a health plan with more than one product in a market
• Explain the difference between primary care HMOs and open access HMOs
• List several sources of laws, regulations, or guidelines on network access and adequacy
• Explain how a tiered network helps a health plan address the cost-access trade-off that health plans typically
encounter when setting the size of the provider panel
• Describe the "build or buy" decision for networks and list some reasons why a health plan might lease a network or
outsource development of a network
Instructions:

Complete the Test

1. 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 Go to
provider panel of the PPO. The POS will be a typical two-level POS that offers question
a cost-based incentive plans for PCPs, and the HMO is a typical staff model 2.
HMO.
The network strategy that Gardenia is using to establish its range of

healthcare plans is known as the
network-within-a-network approach
gatekeeper approach
tiered network approach
preferred tier approach
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 Go to

question
establishment of the PPO and the staff model HMO in its new market: 3.
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.
Both 1 and 2
Neither 1 nor 2
1 Only
2 Only
providers included in the HMO or the POS are included in the broader Go to
provider panel of the PPO. The POS will be a typical two-level POS that offers question
a cost-based incentive plans for PCPs, and the HMO is a typical staff model 4.
HMO.
One statement that can correctly be made about Gardenia’s two-level POS
product is that
members who self-refer without first seeing their PCPs will receive no
benefits
both Gardenia and the PCPs stand to benefit if the non-provider panels
are kept relatively narrow
members will pay higher coinsurance or copayments if they first see
their PCPs each time
the plan offers no financial incentives to members to choose an in-
network specialist over a non-network specialist
4. Health plans are required to follow several regulations and guidelines

Go to
regarding the access and adequacy of their provider networks. The Federal
question
Employee Health Benefits Program (FEHBP) regulations, for example, require 5.
that health plans
allow members direct access to OB/GYN services
allow members direct access to prescription drug services
provide access to Title X family-planning clinics
provide average office waiting times of no more than 30 minutes for
appointments with plan providers
5. Some jurisdictions have enacted corporate practice of medicine laws. One Go to

effect that corporate practice of medicine laws have had on HMO provider question
networks is that these laws typically 6.
require incorporated HMOs to practice medicine through licensed

employees
require HMOs to form exclusive contracts with physician groups who
agree to dedicate all or most of their practices to HMO patients in return
for a set payment or revenue-sharing
restrict the ability of staff model HMOs to hire physicians directly, unless
the physicians own the HMO
encourage incorporated HMOs to obtain profits from their provisions of
physician professional services
Go to
6. The actual number of providers included in a provider network may be
question
based on staffing ratios. Staffing ratios relate the number of 7.
potential providers in a plan’s network to the number of individuals in
the area to be served by the plan
providers in a plan’s network to the number of enrollees in the plan
providers outside a plan’s network to the number of providers in the
plan’s network
support staff in a plan’s network to the number of medical practitioners
in the plan’s network
7. Before incurring the expense of assembling a new PPO network, the

Protect Health Plan conducted a cost analysis in order to determine the cost-
effectiveness of renting an existing PPO network instead. In calculating the
Back to
overall cost of renting the network, Protect assumed a premium of $2.52 per Top
member per month (PMPM) and estimated the total number of members to
be 9,000. This information indicates that Protect would calculate its annual
network rental cost to be
$42,857
$56,700
$272,160
$680,400
>---------- End of the Test ----------<

1 A
2 D
3 D
4 D
5 C
6 B
7 C
Reading 2C: Delegation of Network Management Activities
• Define delegation and sub-delegation

• Explain the difference between "authority" and "accountability" with regard to delegation
• List some reasons why health plans sometimes delegate activities
• Identify and describe the steps in the delegation process
• Describe the primary requirements of the National Committee for Quality Assurance (NCQA) and the American
Accreditation HealthCare Commission (the Commission/URAC) for demonstrating appropriate oversight of
credentialing delegation
Instructions:

Complete the Test

1. The Aegean Health Plan delegated its utilization management (UM)
Go to
program to the Silhouette IPA. Silhouette, in turn, transferred authority for
question
case management to Brandon Health Services. In this situation, Brandon is 2.
best described as the
delegator, and Aegean is ultimately responsible for Brandon’s
performance
delegator, and Silhouette is ultimately responsible for Brandon’s
performance
subdelegate, and Aegean is ultimately responsible for Brandon’s
performance
subdelegate, and Silhouette is ultimately responsible for Brandon’s
performance
2. Although a health plan is allowed to delegate many activities to outside

Go to
sources, the National Committee for Quality Assurance (NCQA) has
question
determined that some activities are not delegable. 3.
These activities include
evaluation of new medical technologies
overseeing delegated medical records activities
developing written statements of members’ rights and responsibilities
all of the above
3. The Brice Health Plan submitted to Clarity Health Services a letter of intent
Back to
indicating Brice’s desire to delegate its demand management function to Top
Clarity. One true statement about this letter of intent is that it
creates a legally binding relationship between Brice and Clarity
most likely contains a confidentiality clause committing Brice and Clarity
to maintain the confidentiality of documents reviewed and exchanged in
the process
prohibits Clarity from performing similar delegation activities for other
health plans
most likely contains a detailed description of the functions that Brice will
delegate to Clarity
>---------- End of the Test ----------<

1 C
2 D
3 B
Assignment 3: Selecting Network Providers
Reading 3A: Identifying and Recruiting Providers for a Health Plan Network
• List and describe the types of providers included in the most managed care networks
• Discuss the factors that a health plan considers when identifying potential network hospitals and practitioners
• Explain the advantages and disadvantages of health plan contracting with individual practitioners and provider
organizations
• Discuss the methods that health plans may use to recruit candidates for their provider networks
Instructions:

Complete the Test

Go to
1. The following statements are about the specialist component of a provider
question
panel. Select the answer choice containing the correct statement. 2.
Ideally, a health plan should have every specialist category represented
on its provider panel with appropriate geographic distribution.
Most specialist contracts do not ensure the provider’s adherence to UM
policies set up by the health plan.
No-balance-billing clauses are not desirable in health plan contracts with
specialists.
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.
2. In contracting with providers, a health plan can use a closed panel or open Go to
panel approach. One statement that can correctly be made about an open question
panel health plan is that the participating providers 3.
must be employees of the health plan, rather than independent

contractors
are prohibited from seeing patients who are members of other health
plans
typically operate out of their own offices
operate according to their own standards of care, rather than standards
of care established by the health plan
3. In open panel contracting, there are several types of delivery systems.

Go to
One such delivery system is the faculty practice plan (FPP). One likely result
question
that a health plan will experience by contracting with an FPP is that the 4.
health plan will
be able to select most of the physicians in the FPP
achieve the highest level of cost effectiveness possible
experience limited control over utilization
achieve the most effective case management possible
4. The following statement(s) can correctly be made about hospitalists.
1. The hospitalist’s main function is to coordinate diagnostic and treatment

Go to
activities to ensure that the patient receives appropriate care while in the
question
hospital. 5.
2. The hospitalist’s role clearly supports the health plan concept of disease
management.
Both 1 and 2
1 only
2 only
Neither 1 nor 2
5. Salvatore Arris is a member of the Crescent Health Plan, which provides its
members with a full range of medical services through its provider network.
After suffering from debilitating headaches for several days, Mr. Arris made
an appointment to see Neal Prater, a physician’s assistant in the Crescent
network who provides primary care under the supervision of physician Dr.
Go to
Anne Hunt. Mr. Prater referred Mr. Arris to Dr. Ginger Chen, an
question
ophthalmologist, who determined that Mr. Arris’ symptoms were indicative of 6.
migraine headaches. Dr. Chen prescribed medicine for Mr. Arris, and Mr. Arris
had the prescription filled at a pharmacy with which Crescent has contracted.
The pharmacist, Steven Tucker, advised Mr. Arris to take the medicine with
food or milk. In this situation, the person who functioned as an ancillary
service provider is
Mr. Prater
Dr. Hunt
Dr. Chen
Mr. Tucker
6. Open panel health plans can contract with individual providers or with
various provider groups when developing their networks. The following Go to
statements are about factors that an open panel health plan might consider question
in contracting with different types of provider organizations. Select the 7.
answer choice that contains the correct statement.
One limitation of contracting with multispecialty groups is that a health
plan obtains only specialty consultants, but not PCPs.
One benefit to a health plan in contracting with an integrated delivery
system (IDS) is the ability to have a network in rapid order and to enter
into a new market or one that is already competitive.
A health plan that contracts with an individual practice association (IPA)
has a greater ability to select and deselect individual physicians than
when contracting directly with the providers.
A health plan that contracts with an IDS is able to eliminate the antitrust
risk that exists when contracting with an IPA.
7. Health plans use a variety of sources to find candidates to recruit for their
Back to
provider networks. In general, two of the most effective methods of finding Top
candidates are through
word of mouth and on-site training programs
word of mouth and direct mail
advertisements in local newspapers and on-site training programs
advertisements in local newspapers and direct mail
>---------- End of the Test ----------<

1 A
2 C
3 C
4 B
5 D
6 B
7 B
Reading 3B: Collecting and Verifying Data for Credentialing Purposes
• Explain the data collection and verification processes used in credentialing and describe their importance to a health
plan's selection of network physicians
• Describe the role played in data collection and verification by:
• American Board of Medical Specialties (ABMS)
• Federation of State medical Boards
• National Practitioner Data Bank (NPDB)
• Healthcare Integrity and Protection Data Bank (HIPDB)
• provider profiling
• Explain the liability issues involved with credentialing decisions, including: requirements of the Americans with
Disabilities Act (ADA), confidentiality, vicarious liability, violation of due process, and negligent credentialing
• Describe how and why health plans delegate credentials verification to third parties
• Describe the data collection and verification services provided by hospitals and medical facilities, Physician
Organization Certification (POC) program, and credentials verification organizations (CVOs)
Instructions:

Complete the Test

1. During the credentialing process, a health plan verifies the accuracy of Go to
information on a prospective network provider’s application. One true question
statement regarding this process is that the health plan 2.
has a legal right to access a prospective provider’s confidential medical

records at any time
must limit any evaluations of a prospective provider’s office to an
assessment of quantitative factors, such as the number of double-
booked appointments a physician accepts at the end of each day
is prohibited by law from conducting primary verification of such data as
a prospective provider’s scope of medical malpractice insurance
coverage and federal tax identification number
must complete the credentialing process before a provider signs the
network contract or must include in the signed document a provision
that the final contract is contingent upon the completion of the
credentialing process
2. The Festival Health Plan is in the process of recruiting physicians for its Go to
question
provider network. Festival requires its network physicians to be board
3.
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

Applicants 1 and 2 are board certified
Applicants 2 and 3 are board certified
Applicant 1 is board certified
Applicant 3 is board certified
3. The Justice Health Plan is eligible to submit reportable actions against

medical practitioners to the National Practitioner Data Bank (NPDB). Justice is
considering whether it should report the following actions to the NPDB:
Action 1—A medical malpractice insurer made a malpractice payment on

behalf of a dentist in Justice’s network for a complaint that was settled out of
court.
Action 2—Justice reprimanded a PCP in its network for failing to follow the
health plan’s referral procedures. Go to
question
4.
Action 3—Justice suspended a physician’s clinical privileges throughout the
Justice network because the physician’s conduct adversely affected the
welfare of a patient.
Action 4—Justice censured a physician for advertising practices that were not
aligned with Justice’s marketing philosophy.
Of these actions, the ones that Justice most likely must report to the NPDB
include Actions
1, 2, and 3 only
1 and 3 only
2 and 4 only
3 and 4 only
4. The NPDB specifies the entities that are eligible to request information
Go to
from the data bank, as well as the conditions under which requests are
question
allowed. In general, entities that are eligible to request information from the 5.
NPDB include
medical malpractice insurers and the general public
medical malpractice insurers and professional societies that are
screening applicants for membership
the general public and state licensing boards
state licensing boards and professional societies that are screening
applicants for membership
5. Participating providers in a health plan’s network must undergo Go to
recredentialing on a regular basis. During recredentialing, a health plan question
typically reviews 6.
a provider’s current, updated application information, as well as

provider’s peer reviews and performance reports on the provider
a provider’s current, updated application information, as well as the
provider’s education and prior work history
a provider’s education and prior work history only
peer reviews and performance reports on a provider and the provider’s
prior work history only
6. With respect to hiring practices, one step that a health plan most likely can Go to
take to avoid violating the terms of the Americans with Disabilities Act (ADA) question
is to 7.
require a medical examination prior to accepting an application for

employment
include in the employment application questions pertaining to health
status
make a conditional offer of employment, and then require the candidate
to have an examination prior to granting specific staff privileges
require applicants to answer questions pertaining to the use of drugs
and alcohol
7. Determine whether the following statement is true or false:
Go to
The NCQA has established a Physician Organization Certification (POC) question
program for the purpose of certifying medical groups and independent 8.
practice associations for delegation of certain NCQA standards, including data
collection and verification for credentialing and recredentialing.
True
False
8. For this question, if answer choices (A) through (C) are all correct, select
answer choice (D). Otherwise, select the one correct answer choice. A Back to
credentials verification organization (CVO) can be certified to verify certain Top
pertinent credentialing information, including
liability claims histories of prospective providers
hospital privileges of prospective providers
malpractice insurance on prospective providers
all of the above
>---------- End of the Test ----------<

1 D
2 C
3 B
4 D
5 A
6 C
7 A
8 D
Assignment 4: Provider Contracting: Part One
Reading 4A: The Provider Contract
• Explain why health plans enter into legal contracts with providers
• Describe the essentials elements of a contractual relationship
• Identify the differences and similarities between a comprehensive and a brief provider contract
• Describe the major elements in a comprehensive contract
• Discuss the goals that a health plan may try to reach through its contractual strategies
Instructions:

Complete the Test

1. The introductory paragraph of a provider contract is generally followed by Go to
a section called the recitals. The recitals section of the contract typically question
specifies the 2.
purpose of the agreement

manner in which the provider is to bill for services
definitions of key terms to be used in the contract
rate at which the provider will be compensated
2. Most health plan contracts provide an outline of the criteria that a

healthcare service must meet in order to be considered “medically Go to
necessary.” Typically, in order for a healthcare service to be considered question
medically necessary, the service provided by a physician or other healthcare 3.
provider to identify and treat a member’s illness or injury must be
consistent with the symptoms of diagnosis
furnished in the least intensive type of medical care setting required by
the member’s condition
in compliance with the standards of good medical practice
all of the above
3. When the Rialto Health Plan determines which of the emergency services
received by its plan members should be covered by the health plan, it is
guided by a standard which describes emergencies as medical conditions
manifesting themselves by acute symptoms of sufficient severity (including Go to
severe pain) such that a person who possesses an average knowledge of question
health and medicine could reasonably expect the absence of immediate 4.
medical attention to result in placing the health of the individual in serious
jeopardy. This standard, which was adopted by the NAIC in 1996, is referred
to as the
medical necessity standard
prudent layperson standard
“all-or-none” standard
reasonable and customary standard
4. The provider contract between the Ocelot Health Plan and Dr. Enos Zorn,
one of the health plan’s participating providers, is a brief contract which
Go to
includes, by reference, an Ocelot provider manual. This manual contains
question
much of the information found in Ocelot’s comprehensive provider contracts. 5.
The following statements are about Dr. Zorn’s provider contract. Select the
answer choice containing the correct statement.
All statements in the provider contract shall be deemed to be warranties,
because all statements of facts contained in the contract must be true
only in those respects material to the contract.
Because the provider manual is part of the contract, Ocelot must make
sure that its provider manual is comprehensive and up-to-date.
Because the provider contract is a brief contract, Ocelot most likely is
prohibited from amending the contract unilaterally, even if it gives Dr.
Zorn advance notice of its intent to amend the contract.
Areas that should be covered in the provider manual, and not in the
body of the contract, include any specific legal issues relevant to the
contract.
5. A provider contract describes the responsibilities of each party to the

Go to
contract. These responsibilities can be divided into provider responsibilities,
question
health plan responsibilities, and mutual obligations. Mutual obligations 6.
typically include
provisions for marketing the plan’s product
payment arrangements between the plan and the provider
verification of the plan’s eligibility to do business
management of the contents of members’ medical records
6. The Medea Clinic is a network provider for Delphic Healthcare. Delphic

Go to
transferred the contract it held with Medea to the Elixir HMO, an entity that
question
was not party to the original contract. The process by which Delphic 7.
transferred the contract it held with Medea to Elixir is known as
most-favored- nation arrangement
a limit on action
a consideration
an assignment
7. Dr. Eve Barlow is a specialist in the Amity Health Plan’s provider network.
Back to
Dr. Barlow’s provider contract with Amity contains a typical most-favored- Top
nation arrangement. The purpose of this arrangement is to
require Dr. Barlow and Amity to use arbitration to resolve any disputes
regarding the contract
specify that the contract is to be governed by the laws of the state in
which Amity has its headquarters
require Dr. Barlow to charge Amity her lowest rate for a medical service
she has provided to an Amity plan member, even if the rate is lower
than the price negotiated in the contract
state that the contract creates an employment or agency relationship,
rather than an independent contractor relationship, between Dr. Barlow
and Amity
>---------- End of the Test ----------<

1 A
2 D
3 B
4 B
5 B
6 D
7 C
Reading 4B: The Negotiation Process for Provider Contracting
• List some circumstances that may result in renegotiation of a provider contract

• List and describe some of the functions that are often represented on health plan and provider negotiating teams
• Describe some types of information that the health plan typically seeks about a provider, and vice versa, when
preparing for provider contract negotiation
• Describe the process for setting objectives for negotiation
Instructions:

Complete the Test

1. Health plan contract negotiations with an integrated delivery system (IDS) Go to
or a hospital are usually lengthier and more complex than negotiations with a question
single-specialty provider. 2.
True
False
2. An health plan’s contract negotiation team consists of several skilled

individuals from different areas. At least one of the members is responsible
Go to
for evaluating the wording of specific clauses to ensure that the health plan’s
question
rights are protected, as well as to ensure that the contract is in compliance 3.
with state and federal regulation. By profession, this member of the contract
negotiation team is typically
a medical director
an attorney
a financial manager
a claims manager
3. The following statements are about the negotiation process of provider

Back to
contracting. Three of the statements are true and one of the statements is Top
false. Select the answer choice containing the FALSE statement.
While preparing for negotiations, the health plan usually sends the
provider an application to join the provider network, a list of
credentialing requirements, and a copy of the proposed provider
contract, which may or may not include the proposed reimbursement
schedule.
In general, the ideal negotiating style for provider contracting is a
collaborative approach.
Typically, the health plan and the provider negotiate the reimbursement
arrangement between the parties before they negotiate the scope of
services and the contract language.
The actual signing of the provider contract typically takes place after
negotiations are completed.
>---------- End of the Test ----------<
1 A
2 B
3 C
Assignment 5: Provider Contracting: Part Two
Reading 5A: Responsibilities of health plans and Providers Under Provider Contracts
• Describe a low-enrollment guarantee clause and explain how health plans use low-enrollment guarantee clauses in
capitated contracts
• Explain two situations in which health plans modify existing provider contracts and two methods of modification
• Describe the issues about physician/patient communication that may be of concern to providers
• List several reasons why a contract with a primary care provider should describe the scope of service in detail
• List and describe three types of termination clauses
• Explain the role of the due process clause in the termination of providers
Instructions:

Complete the Test

1. The following statements are about some of the issues surrounding the Go to
contractual responsibilities of health plans. Select the answer choice question
containing the correct statement. 2.
Typically, health plans are required to pay completed claims within 10

days of submission.
health plans typically are prohibited from examining the financial
soundness of a self-funded employer plan that relies on the health plan
to pay providers for services received by the plan’s members.
Patient delivery is one of the most significant factors that health plans
consider when determining whether provider services should be
reimbursed on a capitated or fee-for-service (FFS) basis.
health plans require all providers to agree to an exclusive provider
contract.
2. From the following answer choices, choose the type of clause or provision
described in this situation.
Go to
question
The Idlewilde Health Plan includes in its provider contracts a clause or 3.
provision that allows the terms of the contract to renew unchanged each
year.
Cure provision
Hold-harmless provision
evergreen clause
Exculpation clause
3. From the following answer choices, choose the type of clause or provision Go to
question
4.
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.
Cure provision
Evergreen clause
Exculpation clause
4. From the following answer choices, choose the type of clause or provision
Go to
question
The Aviary Health Plan includes in its provider contracts a clause or provision 5.
that places the ultimate responsibility for an Aviary plan member’s medical
care on the provider.
Cure provision
Evergreen clause
Exculpation clause
5. The following statements are about the responsibilities that providers are Go to
expected to assume under most provider contracts with health plans. Select question
the answer choice containing the correct statement. 6.
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.
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.
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.
Most provider contracts require participating providers to discuss health
plan payment arrangements with patients who are covered by the plan.
Go to
6. With respect to contractual provisions related to provider-patient
question
communications, nonsolicitation clauses prohibit providers from 7.
encouraging patients to switch from one health plan to another

disclosing confidential information about the health plan’s
reimbursement structure
dispersing confidential financial information regarding the health plan
discussing alternative treatment plans with patients
7. The provider contract that Dr. Huang Kwan has with the Poplar Health Plan
includes a typical scope of services provision. The medical service that Dr.
Kwan provided to Alice Meyer, a Poplar plan member, is included in the scope
of services. The following statement(s) can correctly be made about this
particular medical service: Go to
question
A. Dr. Kwan most likely was required to seek authorization from Poplar 8.
before performing this particular service.
B. Dr. Kwan most likely was paid on a FFS basis for providing this
service.
Both A and B
A only
B only
Neither A nor B
8. If a third party is responsible for injuries to a plan member of the Hope

Go to
Health Plan, then Hope has a contractual right to file a claim for the resulting
question
healthcare costs against the third party. This contractual right to recovery 9.
from the third party is known as
subrogation
partial capitation
coordination of benefits
a remedy provision
9. The Octagon Health Plan includes a typical indemnification clause in its Go to

provider contracts. The purpose of this clause is to require Octagon’s network question
providers to 10.
agree not to sue or file claims against an Octagon plan member for
covered services
reimburse Octagon for costs, expenses, and liabilities incurred by the
health plan as a result of a provider’s actions
maintain the confidentiality of the health plan’s proprietary information
agree to accept Octagon’s payment as payment in full and not to bill
members for anything other than contracted copayments, coinsurance,
or deductibles
10. The provider contract between the Regal Health Plan and Dr. Caroline
Back to
Quill contains a type of termination clause known as termination without Top
cause. One true statement about this clause is that it
requires Regal to send a report to the appropriate accrediting agency if
the health plan terminates Dr. Quill’s contract without cause
requires that Regal must base its decision to terminate Dr. Quill’s
contract on clinical criteria only
allows either Regal or Dr. Quill to terminate the contract at any time,
without any obligation to provide a reason for the termination or to offer
an appeals process
allows Regal to terminate Dr. Quill’s contract at the time of contract
renewal only, without any obligation to provide a reason for the
termination or to offer an appeals process
>---------- End of the Test ----------<

1 C
2 C
3 A
4 D
5 C
6 A
7 D
8 A
9 B
10 C
Reading 5B: Compensation Arrangements Between health plans and Providers
• Explain how an MCO transfers financial risk to providers through reimbursement arrangements
• Describe the primary advantages and disadvantages of fee-for-service, salary, and capitation payment systems
• List and describe four types of capitation
• Explain how health plans use incentives in compensation arrangements
• List and describe four ways to manage a provider's financial risk
• Describe some factors that influence the way a health plan compensates its providers
Instructions:

Complete the Test

1. 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
Go to
Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The
question
services she actually provided represented an intermediate level of service. 2.
Dr. Sanderson’s action is an example of a type of false billing procedure
known as
cost shifting
churning
unbundling
upcoding
2. The Sweeney Health Plan uses the discounted fee-for-service (DFFS) Go to

method to compensate some of its providers. Under this method of question
compensation, Sweeney calculates payments based on 3.
the standard fees of indemnity health insurance plans, adjusted by

region
the Medicare fee schedules used by other health plans, adjusted by
region
whichever amount is higher, the billed charge or the DFFS amount
whichever amount is lower, the billed charge or the DFFS amount
3. 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 Go to
service. Under this system, the unit values for procedural services are question
generally higher than the unit values for cognitive services. This system is 4.
known as a
wrap-around payment system
relative value scale (RVS) payment system
resource-based relative value scale (RBRVS) system
capped fee system
Go to
4. One true statement about the compensation arrangement known as the
question
case rate system is that, under this system, 5.
providers stand to gain or lose based on the number and types of
treatments used for each case
providers have no incentives to take an active role in managing cost and
utilization
payors cannot adjust standard case rates to reflect the severity of the
patient’s condition or complications that arise from multiple medical
problems
payors have the opportunity to benefit from the provider’s cost savings
5. Health plans often negotiate compensation arrangements that transfer

some or all of the financial risk associated with delivering healthcare services Go to
to network providers. The following statements are about these question
compensation arrangements. Select the answer choice containing the correct 6.
statement.
A per diem system typically places a healthcare facility at risk for
controlling utilization and costs internally.
One likely reason that an health plan would use a fee schedule system to
compensate providers is that this system transfers most of the financial
risk to the provider.
Under a salary system, a provider assumes no service risk.
The use of a FFS or a salary system allows an health plan to transfer a
greater proportion of financial risk to providers than does the use of
capitation.
Go to
6. An health plan enters into a professional services capitation arrangement
question
whenever the health plan 7.
contracts with a medical group, clinic, or multispecialty IPA that assumes
responsibility for the costs of all physician services related to a patient’s
care
pays individual specialists to provide only radiology services to all plan
members
transfers all financial risk for healthcare services to a provider
organization and the provider, in turn, covers virtually all of a patient’s
medical expenses
contracts with a primary care provider to cover primary care services
only
Go to
7. The following statements are about incentive programs used for providers.
question
Select the answer choice containing the correct statement. 8.
Risk pools based on aggregate provider performance eliminate problems
associated with “free riders.”
A hospital bonus pool is usually split between the health plan and the
PCPs.
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.
For providers, withhold arrangements eliminate the risk of losing base
income.
8. To protect providers against business losses, many health plan-provider

contracts include carve-out provisions to help providers manage financial
risk. The following statements are examples of such provisions.
• The Apex Health Plan carves out immunizations from PCP capitations.
Go to
Apex compensates PCPs for immunizations on a case rate basis.
question
• The Bengal Health Plan carves out behavioral healthcare services from 9.
the scope of PCP services because these services require specialized
knowledge and skills that most PCPs do not possess.
From the answer choices below, select the response that best identifies the
types of carve-outs used by Apex and Bengal.
Apex: disease-specific carve-out
Bengal: specialty services carve-out
Apex: disease-specific carve-out
Bengal: specific-service carve-out
Apex: specific-service carve-out
Bengal: specialty services carve-out
Apex: specific-service carve-out
Bengal: disease-specific carve-out
9. The Athena Medical Group has purchased from the Corinthian Insurance
Company individual stop-loss insurance coverage for primary and specialty
Go to
care services with a $5,000 attachment point and 10 percent coinsurance.
question
One of Athena’s patients accrued $8,000 of medical costs for primary and 10.
specialty care treatment. In this situation, Athena will be responsible for
paying an amount equal to
$300, and Corinthian is obligated to reimburse Athena in the amount of
$2,700
$2,700, and Corinthian is obligated to reimburse Athena in the amount
of $5,300
of $2,700
of $300
10. The Ionic Group, a provider group with 10,000 plan members, purchased
for its hospital risk pool aggregate stop-loss insurance with a threshold of
110% of projected costs and a 10% coinsurance provision. Ionic funds the
Back to
hospital risk pool at $40 per member per month (PMPM). If Ionic’s actual Top
hospital costs are $5,580,000 for the year, then, under the aggregate stop-
loss agreement, the stop-loss insurer is responsible for reimbursing Ionic in
the amount of
$30,000
$270,000
$300,000
$702,000
>---------- End of the Test ----------<

1 D
2 D
3 B
4 A
5 A
6 A
7 B
8 C
9 C
10 B
Assignment 6: Network Management Considerations for Different Types of Providers
Reading 6A: Strategies for the Specialist Component of the Provider Network
• Describe some of the challenges health plans face when contracting with hospital-based specialists
• Describe the different reimbursement options that health plans typically use for specialists
• Discuss some common problems that health plans encounter when using capitation for specialty care
Instructions:

Complete the Test

1. 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

Go to
Autumn accumulates one point for each new referral made to the specialist
question
by Autumn’s PCPs. If the referral is classified as complicated, then the 2.
dermatologist receives 1.5 points. The value of Autumn’s dermatology
services fund for the first quarter was $15,000. During the quarter, Autumn’s
PCPs made 90 referrals, and 20 of these referrals were classified as
complicated.
Autumn’s method of reimbursing specialty providers can best be described as

a
disease-specific arrangement
contact capitation arrangement
risk adjustment arrangement
withhold arrangement
2. The method that the Autumn Health Plan uses for reimbursing Go to
question
dermatologists in its provider network involves paying them out of a fixed
3.
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 Autumn’s PCPs. If the referral is classified as complicated, then the
dermatologist receives 1.5 points. The value of Autumn’s dermatology
services fund for the first quarter was $15,000. During the quarter, Autumn’s
PCPs made 90 referrals, and 20 of these referrals were classified as
complicated.
In determining the first quarter payment to dermatologists, Autumn would

accurately calculate the value of each referral point to be
$111.11
$125.00
$150.00
$166.67
3. Dr. Janet Dubois is a radiologist who practices exclusively at the Rightway Go to

Healthcare Center. This information indicates that Dr. Dubois is employed by question
Rightway as 4.
an academic practitioner
an independent practitioner
a network manager
a hospital-based specialist
4. Promise, Inc., a corporation that specializes in cancer services, employs its

physicians and support staff and provides facilities and ancillary services for
cancer patients. Promise has contracted with the Cordelia Health Plan to Go to
provide all specialty services for Cordelia plan members who are undergoing question
cancer treatment. In return, Promise receives a capitated amount from 5.
Cordelia. Promise is an example of a type of specialty services organization
known as a
specialty IPA
disease management company
single specialty management specialist
specialty network management company
5. If the Oconee Health Plan reimburses its specialty care physicians (SCPs) Back to
under a typical retainer method, then Oconee pays SCPs Top
a separate amount for each service provided, and the payment amount
is based solely on a resource-based relative value scale (RBRVS)
a specified fee that remains the same regardless of how much or how
little time or effort is spent on the medical service performed
a set amount each month, and Oconee reconciles its payment at periodic
intervals on the basis of actual utilization
a set amount of cash equivalent to a defined time period’s expected
reimbursable charges
>---------- End of the Test ----------<

1 B
2 C
3 D
4 B
5 C
Reading 6B: Strategies for Contracting with Hospitals and Subacute Care Facilities
• Explain why health plans sometimes contract with centers of excellence

• List issues that a health plan considers when selecting a center of excellence
• List and describe methods that health plans commonly use to reimburse hospitals for inpatient and outpatient
services
• Define ambulatory payment classifications (APCs) and compare this system to diagnosis-related groups (DRGs)
• Explain why health plans contract with facilities for subacute care and describe the main criteria for selecting
subacute care providers
Instructions:

Complete the Test

1. One reimbursement method that health plans can use for hospitals is the
ambulatory payment classifications (APCs) method. APCs bear a resemblance Go to
to the diagnosis-related groups (DRGs) method of reimbursement. However, question
when comparing APCs and DRGs, one of the primary differences between the 2.
two methods is that only the APC method
is typically used for outpatient care
assigns a single code for treatment
applies to treatment received during an entire hospital stay
is considered to be a retrospective payment system
Go to
2. Four types of APCs are ancillary APCs, medical APCs, significant procedure
question
APCs, and surgical APCs. An example of a type of APC known as 3.
an ancillary APC is a biopsy

a medical APC is radiation therapy
a significant procedure APC is a computerized tomography (CT) scan
a surgical APC is an emergency department visit for cardiovascular
disease
3. The Gladspell HMO has contracted with the Ellysium Hospital to provide
subacute care to its plan members. Gladspell pays Ellysium by using a per Go to
diem reimbursement method. question
4.
The per diem reimbursement method will require Gladspell to pay Ellysium a
fixed rate for each day a plan member is treated in Ellysium’s subacute
care facility
discounted charge for all subacute care services given by Ellysium
rate that varies depending on patient category
fixed rate per enrollee per month
subacute care to its plan members. Gladspell pays Ellysium by using a per
diem reimbursement method. Go to
question
5.
If Gladspell’s per diem contract with Ellysium is typical, then the per diem
payment will cover such medical costs as
laboratory tests
respiratory therapy
semiprivate room and board
radiology services
subacute care to its plan members. Gladspell pays Ellysium by using a per
diem reimbursement method.
Back to
Top
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
daily medical care and monitoring
regular rehabilitative therapy
respiratory therapy
all of the above
>---------- End of the Test ----------<

1 A
2 C
3 A
4 C
5 D
Reading 6C: Pharmacy Networks
• Describe the advantages early pharmacy networks had over direct pay and cost-sharing pharmacy systems
• Identify the features that distinguish pharmacy networks from other health plan networks
• Describe the impact of pharmacy benefits management in managed care
• Explain the advantages and disadvantages of maintaining in-house management of pharmacy benefits or
outsourcing benefits through a pharmacy benefit management company (PBM)
• Describe the options available for delivering pharmacy services
• Identify the methods that health plans and PBMs use to reimburse network pharmacies
Instructions:

Complete the Test

1. The method of pharmaceutical reimbursement under which a plan member Go to
obtains prescription drugs from participating network pharmacies by question
presenting proper identification and paying a specified copayment is the 2.
wholesale acquisition cost (WAC) approach

reimbursement approach
service approach
cognitive approach
2. In most health plan pharmacy networks, the cost component of the Go to

reimbursement formula is based on the average wholesale price (AWP). One question
true statement about the AWP for prescription drugs is that 3.
AWPs tend to vary widely from region to region of the United States
the AWP is often substantially higher than the actual price the pharmacy
pays for prescription drugs
a health plan’s contracted reimbursement to a pharmacy for prescription
drugs is typically the AWP plus a percentage, such as 5%
the AWP usually is lower than the estimated acquisition cost (EAC) for
most prescription drugs
3. In the paragraph below, two statements each contain a pair of terms Go to

question
enclosed in parentheses. Determine which term correctly completes each
4.
statement. Then select the answer choice that contains the two terms you
have chosen.
A formulary lists the drugs and treatment protocols that are considered to be
the preferred therapy for a given managed population. The Fairfax Health
Plan uses the type of formulary which covers drugs that are on its preferred
list as well as drugs that are not on its preferred list. This information
indicates that Fairfax uses the (closed / open) formulary method. In using the
formulary approach to pharmacy benefits management, Fairfax most likely
experiences (higher / lower) costs for its members’ prescription drugs than it
would if it did not use a formulary.
closed / higher
closed / lower
open / higher
open / lower
4. The following statements are about the inclusion of unified pharmacy Go to

benefits in health plan healthcare packages. Select the answer choice question
containing the correct statement. 5.
When pharmacy benefits management is incorporated into an health

plan’s operations as a unified benefit, the health plan establishes
pharmacy networks, but a pharmacy benefits management (PBM)
company manages their operations.
Under a unified pharmacy benefit, an health plan cannot use mail-order
services to provide drugs to its members.
Compared to programs that do not manage pharmacy benefits in-house,
unified pharmacy benefits programs typically give health plans more
control over patient access to prescription drugs.
Compared to programs that do not manage pharmacy benefits in-house,
unified pharmacy benefits programs make drug therapy interventions for
plan members more difficult.
5. The following statements can correctly be made about the advantages and Go to
disadvantages to an health plan of using the various delivery options for question
pharmacy services. 6.
A disadvantage of using open pharmacy networks is that the health

plan’s control over costs is limited to setting reimbursement levels.
An advantage of using performance-based systems is that they tend to
increase participation in the health plan’s pharmacy network.
A disadvantage of using customized pharmacy networks is that these
networks typically can be implemented only in companies with fewer
than 500 employees.
All of these statements are correct.
6. The Walton Health Plan uses the fee-for-service pharmaceutical

reimbursement approach known as the maximum allowable cost (MAC) Go to
method. If Walton’s MAC list specifies a cost of 8 cents per tablet for a question
particular drug but the participating pharmacy pays 10 cents per tablet for 7.
the drug, then Walton will be obligated to reimburse the pharmacy for
8 cents per tablet, but the pharmacy can bill the subscriber for the
remaining 2 cents per tablet
8 cents per tablet, and the pharmacy cannot bill the subscriber for the
remaining 2 cents per tablet
10 cents per tablet, but the pharmacy must refund the extra 2 cents per
tablet to the subscriber
10 cents per tablet, and the pharmacy is not required to refund the extra
2 cents per tablet to the subscriber
7. One reason that an health plan would want to use the actual acquisition
Back to
cost (AAC) pricing system to calculate its drug costs is that, of the systems Top
commonly used to calculate drug costs, the AAC system
provides the lowest level of cost for the health plan
most closely represents what pharmacies are actually charged for
prescription drugs
offers the best control over multiple-source pharmaceutical products
is the least expensive pricing system for the health plan to implement
>---------- End of the Test ----------<

1 C
2 B
3 D
4 C
5 A
6 B
7 A
Reading 6D: Considerations and Strategies for Specialty Services
• Explain some of the different carve-out arrangements that an MCO may use to arrange access to specialty services
• Describe the criteria a health plan uses to select a sole-source provider for specialty services
• Explain how the role of the PCP in behavioral healthcare varies among health plans
• Explain health plan's options for arranging access to clinical eye care and routine eye care
• Distinguish between ophthalmologists, optometrists, opticians
• List some reasons health plans often find the development and management of alternative healthcare networks to be
challenging
• List some ways in which a home healthcare agency can prepare itself to accept capitated contracts
Instructions:

Complete the Test

1. 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)

Go to
• The Baxter Managed Behavioral Healthcare Organization (MBHO)
question
• The Cheshire Dental Health Maintenance Organization (DHMO) 2.
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
Apex and Baxter only
Apex and Cheshire only
Baxter and Cheshire only
Baxter only
2. Many health plans opt to carve out behavioral healthcare (BH) services. Go to
However, one argument against carving out BH services is that this action question
most likely can result in 3.
slower access to BH care for plan members

increased collaboration between BH providers and PCPs
fewer specialized BH services for plan members
decreased continuity of BH care for plan members
3. The following statements are about managed dental care. Three of these Go to
statements are true, and one is false. Select the answer choice containing the question
FALSE statement. 4.
Managed dental care is federally regulated.
Dental HMOs typically need very few healthcare facilities because almost
all dental services are delivered in an ambulatory care setting.
Currently, there are no nationally recognized standards for quality in
managed dental care.
Processes for selecting dental care providers vary greatly according to
state regulations on managed dental care networks and the health plan’s
standards.
4. Jay Mercer is covered under his health plan’s vision care plan, which
Go to
includes coverage for clinical eye care but not for routine eye care. Recently,
question
Mr. Mercer had a general eye examination and got a prescription for 5.
corrective lenses. Mr. Mercer’s vision care plan will cover.
both the general eye examination and the prescription for corrective
lenses
the general eye examination only
the prescription for corrective lenses only
neither the general eye examination nor the prescription for corrective
lenses
5. An increasing number of health plans offer coverage for alternative Go to

healthcare services. One such alternative healthcare service is biofeedback. question
Biofeedback is an approach that 6.
is based on an ancient Chinese system of healing in which needles are

inserted into specific sites on the body to relieve pain
treats diseases with tiny doses of substances which, in healthy people,
are capable of producing symptoms like those of the disease being
treated
uses electronic monitoring devices to teach a patient to develop
conscious control of involuntary bodily functions, such as heart rate and
body temperature
incorporates a variety of therapies, such as homeopathy, lifestyle
modification, and herbal medicines, to support and maintain the body’s
ability to heal itself
6. The provider contract that the Danube Health Plan has with the Viola Home Back to
Top
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
1½ 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:
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.
Both A and B
A only
B only
Neither A nor B
>---------- End of the Test ----------<

1 D
2 D
3 A
4 D
5 C
6 C
Assignment 7: Establishing Networks for Government-Sponsored Programs
Reading 7A: Special Considerations for Medicare Networks
• Identify federal legislation that has affected the Medicare program and describe its impact on Medicare health plan
• List the three types of health plans that are authorized to apply for Medicare contracts under the Medicare + Choice
programs, and identify the two types of health plans that are allowed to establish closed networks of providers
• Describe the steps that Medicare + Choice health plans must take to ensure that network services are available and
accessible to enrollees
• Describe the restrictions on the use of physician incentive plans by Medicare + Choice health plans
• Discuss several other HCFA regulations affecting the relationship between Medicare + Choice health plans and
network providers
• Discuss some special needs of Medicare beneficiaries that health plans should consider when establishing Medicare
networks
Instructions:

Complete the Test

1. Prior to the enactment of the Balanced Budget Act (BBA) of 1997, payment Go to
for Medicare-covered primary and acute care services was based on the question
adjusted average per capita cost (AAPCC). The AAPCC is defined as the 2.
average cost of services delivered to all patients living in a specified

geographic region
actuarial value of the deductible and coinsurance amounts for basic
Medicare-covered benefits
fee-for-service amount that the Centers for Medicaid and Medicare
Services (CMS) would pay for a Medicare beneficiary, adjusted for age,
sex, and institutional status
average fixed monthly fee paid by all Medicare enrollees in a specified
geographic region
2. The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 allowed
Go to
competitive medical plans (CMPs) to participate in the Medicare program on a
question
risk basis. Under the terms of Medicare risk contracts, CMPs were required to 3.
deliver all medically necessary Medicare-covered services in return for a
fixed monthly capitation payment from CMS
fee-for-service payment from the appropriate state Medicare agency
mandatory premium paid by plan enrollees
fee equal to twice the actuarial value of the Medicare deductible and
coinsurance paid by plan enrollees
3. Social health maintenance organizations (SHMOs) and Programs of All- Go to

Inclusive Care for the Elderly (PACE) are federal programs designed to question
provide coordinated healthcare services to the elderly. Unlike PACE, SHMOs 4.
are reimbursed solely through Medicaid programs

provide extensive long-term care
are reimbursed on a fee-for-service basis
limit benefits to a specified maximum amount
4. Franklin Pitt selected a Medicare+Choice option under which he is covered

by a catastrophic health insurance policy with a high annual deductible and a
$6,000 out-of-pocket expense maximum. CMS pays the premiums for the
insurance policy out of the usual Medicare+Choice payment and deposits any Go to
difference between the capitated amount and the policy premium in a savings question
account. Mr. Pitt can use funds in the savings account to pay qualified 5.
medical expenses not covered by his insurance policy. At the end of the
benefit year, Mr. Pitt can carry any remaining funds into the next benefit
year. The Medicare+Choice option Mr. Pitt selected is known as a
coordinate care plan (CCP)
medical savings account (MSA) plan
competitive medical plan (CMP)
Medicare Risk HMO program
5. The BBA of 1997 specifies the ways in which a Medicare+Choice plan can Go to
establish and use provider networks. A Medicare+Choice plan that operates question
as a private fee for service (PFFS) plan is allowed to 6.
limit the size of its network to the number of providers necessary to

meet the needs of its enrollees
require providers to accept as payment in full an amount no greater than
115% of the Medicare payment rate
refuse payment to non-network providers who submit claims for
Medicare-covered expenses
shift all risk for Medicare-covered services to network providers
6. As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy Go to

CMS requirements regulating access to covered services. In order to ensure question
that its network provides adequate access, Brightwell must 7.
allow enrollees to determine whether they will receive primary care from
a physician, nurse practitioner, or other qualified network provider
base a provider’s participation in the network, reimbursement, and
indemnification levels on the provider’s license or certification
define its service area according to community patterns of care
require enrollees to obtain prior authorization for all emergency or
urgently needed services
7. Dr. Ahmad Shah and Dr. Shantelle Owen provide primary care services to Go to
question
Medicare+Choice enrollees of health plans under the following physician
8.
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

both Dr. Shah and Dr. Owen
Dr. Shah only
Dr. Owen only
neither Dr. Shah nor Dr. Owen
8. Stop-loss insurance is designed to protect physicians who face substantial Go to

financial risk as a result of physician incentive plans. Medicare+Choice health question
plans must ensure that a physician has adequate stop-loss protection if the 9.
physician has a patient panel that exceeds 25,000 patients

physician receives a bonus that is based solely on quality of care, patient
satisfaction, or physician participation
difference between the physician’s maximum potential payments and his
or her minimum potential payments is less than 25% of the maximum
potential payments
physician is subject to a withhold that is greater than 25% of his or her
potential payments
9. CMS Medicare+Choice regulations include a provision that allows health

plans to deny benefits for any services the health plan objects to on moral or Back to
religious grounds. The provision that exempts health plans from providing Top
such services is known as
a conscience protection exception
a hold harmless clause
a medical necessity determination
an intermediate sanction
>---------- End of the Test ----------<
1 C
2 A
3 D
4 B
5 B
6 C
7 C
8 D
9 A
Reading 7B: Special Considerations for Medicaid Networks
• Explain the origin and purpose of the Medicaid program

• Describe the characteristics of the three major segments of the Medicaid population and the challenges these groups
present for health plans
• Define a safety net provider and explain the role that safety net providers can play in Medicaid managed care
• Define the two types of Medicaid managed care entities (MCEs)- managed care organizations (MCOs) and primary
care case managers (PCCMs)
• Explain the differences between open contracting and selective contracting
• Discuss some of the challenges that health plans face in applying managed care strategies to Medicaid
• Describe the type of information a health plan might include in its response to a Medicaid Request for Proposal
(RFP)
• Explain some of the important considerations in a Medicaid-MCO managed care contract
• List some of the questions a health plan might ask when credentialing providers for a Medicaid network
• Discuss the compensation of Medicaid providers, including creative compensation methods that health plans can
use
Instructions:

Complete the Test

1. Medicaid is a joint federal and state program that provides healthcare Go to
coverage for low-income, medically needy, and disabled individuals. Under question
the terms of this joint sponsorship, the 2.
federal government is responsible for making all claim payments

federal government is responsible for determining the basic benefits that
must be provided to eligible Medicaid beneficiaries
state governments are responsible for setting minimum standards
regarding eligibility, benefit coverage, and provider participation and
reimbursement
state governments are responsible for establishing overall regulation of
the Medicaid program
2. Medicaid beneficiaries pose a challenge for health plans attempting to Go to

establish Medicaid provider networks. Compared to membership in question
commercial health plans, Medicaid enrollees typically 3.
require access to greater numbers of obstetricians and pediatricians

have stronger relationships with primary care providers
are less reliant on emergency rooms as a source of first-line care
need fewer support and ancillary services
3. Martin Breslin, age 72 and permanently disabled, is classified as dually- Go to

eligible. This information indicates that Mr. Breslin qualifies for coverage by question
both 4.
Medicare and private indemnity insurance, and Medicare provides

primary coverage
Medicare and Medicaid, and Medicare provides primary coverage
Medicaid and private indemnity insurance, and Medicaid provides
primary coverage
Medicare and Medicaid, and Medicaid provides primary coverage
4. Since 1981, states have had the option to experiment with new
Go to
approaches to their Medicaid programs under the “freedom of choice”
question
waivers. Under one such waiver, a Section 1915(b) waiver, states are 5.
allowed to
give Medicaid recipients complete freedom in choosing healthcare
providers
give Medicaid recipients the option to choose not to enroll in a
healthcare plan
mandate certain categories of Medicaid recipients to enroll in health
plans
establish demonstration projects to test new approaches for delivering
care to Medicaid recipients
5. There are several approaches to providing Medicaid health plan. One such
Go to
approach involves the use of organizations who contract with the state’s
question
Medicaid agency to provide primary care as well as administrative services. 6.
These organizations are known as
enrollment brokers
primary care case managers (PCCMs)
certified medical assistants (CMAs)
prepaid health plans (PHPs)
6. State Medicaid agencies can contract with health plans through open Go to
contracting or selective contracting. One advantage of selective contracting is question
that it 7.
allows enrollees to choose from among a greater variety of health plans

reduces the competition among health plans
increases the ability of new, local plans to participate in Medicaid
programs
encourages the development of products that offer enhanced benefits
and more effective approaches to health plans
7. The Portway Hospital is qualified to receive Medicaid subsidy payments as

Back to
a disproportionate share hospital (DHS). The DHS payments that Portway Top
receives are
made for services rendered to specific patients
made with matching state and federal funds
included in the Medicaid capitation payment made to patients’ health
plans
defined as cost-based reimbursement (CBR) equal to 100% of Portway’s
reasonable costs of providing services to Medicaid recipients
>---------- End of the Test ----------<

1 B
2 A
3 B
4 C
5 B
6 D
7 B
Reading 7C: Provider Networks for Workers' Compensation
• Explain why a state might want to institute managed workers' compensation

• Explain why the selection process for workers' comp providers differs from that for other types of networks
• Describe some of the nonfinancial tools that a health plan can use to manage the performance of its workers' comp
providers
Instructions:

Complete the Test

1. Grant Pelham is covered by both a workers’ compensation program and a
group health plan provided by his employer. The Shipwright Health Plan
administers both programs. Mr. Grant was injured while on the job and
applied for benefits. Go to
question
2.
Mr. Pelham’s group health insurance plan and workers’ compensation both
provide benefits to cover expenses incurred as a result of illness or injury.
However, unlike traditional group insurance coverage, workers’ compensation
provides reimbursement for lost wages
requires employees who suffer a work-related illness or injury to obtain
care from specified network providers
covers all injuries and illnesses, regardless of their cause
requires employees to share the cost of treatment through deductible,
coinsurance, and benefit limits
2. Grant Pelham is covered by both a workers’ compensation program and a

applied for benefits. Go to
question
3.
Because Mr. Pelham was injured on the job, he is entitled to receive benefits
through workers’ compensation. Under the terms of the state-mandated
exclusive remedy doctrine included in the workers’ compensation agreement,
Mr. Pelham will most likely be prohibited from
receiving workers’ compensation benefits unless he can show that the
employer was at fault for his injury
obtaining care from providers who are not members of a workers’
compensation network
suing his employer for additional benefits
claiming benefits from both workers’ compensation and his group health
plan
3. Grant Pelham is covered by both a workers’ compensation program and a Go to

question
4.
applied for benefits.
The provider network that Shipwright uses to furnish services for its workers’
compensation program will most likely
emphasize primary care and consist mostly of generalists
focus treatment approaches on rapid recovery rather than cost
offer workers’ compensation beneficiaries the same types and levels of
treatment that Shipwright’s traditional network furnishes to group health
plan members
exempt participating providers from meeting standard credentialing
requirements
4. Health plans can often reduce workers’ compensation costs by Go to

incorporating 24-hour coverage into their workers’ compensations programs. question
Twenty-four-hour coverage reduces costs by 5.
maximizing the effects of cost shifting

eliminating the need for utilization management
requiring members to use separate points of entry for job-related and
non-job related services
combining administrative services for workers’ compensation and non-
workers’ compensation healthcare and disability coverage
5. In most states, workers’ compensation is first-dollar and last-dollar Back to

coverage, which means that workers’ compensation programs Top
can place limits on the benefits they will pay for a given claim
can deny coverage for work-related illness or injury if the employer is
not at fault
must pay 100% of work-related medical and disability expenses
can hold employers liable for additional amounts that result from court
decisions
>---------- End of the Test ----------<

1 A
2 C
3 B
4 D
5 C
Assignment 8: Ongoing Management of Provider Networks
Reading 8A: Continuing Management of Network Adequacy and Provider Satisfaction
• Describe some situations that may indicate a need to review network adequacy
• List several factors that health plans examine when reassessing access and availability
• Explain the importance of provider retention
• Describe several methods that health plans use to provide continuing education to network providers and their staff
• Explain how direct referral and self-referral programs assist providers with utilization management
• List some of the issues that a health plan typically addresses through surveys of providers and their staffs
• Explain why health plans often seek to involve network providers in network management and medical
management operations
Instructions:

Complete the Test

1. Before or during the orientation process, health plans generally provide Go to
new network providers with a provider manual. One of the primary purposes question
of the provider manual is to 2.
provide a directory of contracted providers

help providers and their staffs develop methods of improving the
operation of their practices
provide feedback to providers regarding their performance
reinforce and document contractual provisions
Go to
2. The Elizabethan Health Plan uses a direct referral program, which means
question
that 3.
PCPs in Elizabethan’s network can make most referrals without obtaining
prior authorization from Elizabethan
PCPs in Elizabethan’s network must always refer plan members to other
specialists within the network
Elizabethan’s plan members can bypass the PCP and obtain medical
services from a specialist without a referral
Elizabethan’s plan members must obtain referrals directly from
Elizabethan
3. The Blanchette Health Plan uses a method of claims submission that allows
its providers to submit claims directly to Blanchette through a computer Go to
application-to-application exchange of claims using a standard data format. question
This information indicates that Blanchette allows its providers to submit 4.
claims using technology known as
telemedicine
an electronic referral system
electronic data interchange
encounter reporting
4. Dr. Sarah Carmichael is one of several network providers who serve on

one of the Apex Health Plan’s organizational committees. The committee
reviews cases against providers identified through complaints and grievances
or through clinical monitoring activities. If needed, the committee formulates, Back to
approves, and monitors corrective action plans for providers. Although Apex Top
administrators and other employees also serve on the committee, only
participating providers have voting rights. The committee that Dr. Carmichael
serves on is a
utilization management committee
peer review committee
medical advisory committee
credentialing committee
>---------- End of the Test ----------<

1 D
2 A
3 C
4 B
Reading 8B: Managing Provider Performance
• Explain why health plans measure the performance of network providers

• Describe how provider profiling is important in performance measurement and performance management
• Describe the following types of performance measures:
• Structure
• Process
• Outcomes
• Patient satisfaction
• Explain how outcomes research and outcomes measurement can be used to benchmark provider performance
• Describe some of the methods health plans can use to change provider behavior
Instructions:

Complete the Test

1. 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 Go to
question
other providers outside the network, with the goal of identifying and 2.
implementing the practices that lead to the best outcomes.
Qualitative measures that Azure could use to assess provider performance

include an evaluation of how
quickly the provider responds to plan members’ inquiries
effectively the provider communicates with plan members
often the provider refers plan members for ancillary services
many plan members visit the provider per month
2. 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 Go to
question
other providers outside the network, with the goal of identifying and 3.
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
case mix analysis
outcomes research
benchmarking
provider profiling
3. Dr. Sylvia Cimer and Dr. Andrew Donne are obstetrician/gynecologists who
participate in the same provider network. Dr. Comer treats a large number of
high-risk patients, whereas Dr. Donne’s patients are generally healthy and
rarely present complications. As a result, Dr. Comer typically uses medical Go to
resources at a much higher rate than does Dr. Donne. In order to equitably question
compare Dr. Comer’s performance with Dr. Donne’s performance, the health 4.
plan modified its evaluation to account for differences in the providers’
patient populations and treatment protocols. The health plan modified Dr.
Comer’s and Dr. Donne’s performance data by means of
a case mix/severity adjustment
an external performance standard
structural measures
behavior modification
4. The Edgewood Health Plan uses a combination of structural, process,

Go to
outcomes, and customer satisfaction measures to evaluate its network
question
providers’ performance. Edgewood would correctly use outcomes measures to 5.
evaluate a provider’s
compliance with specific regulatory or accrediting requirement
appropriate use of specified procedures
patient progress following treatment
patient perceptions about how well the provider addresses medical
problems
5. Member satisfaction surveys help an health plan determine whether its

providers are consistently delivering services to plan members in a manner Back to
that lives up to member expectations. Member satisfaction surveys allow the Top
health plan to gather information about
a member’s reaction to services received during a specific encounter
the reactions of specific subsets of the health plan’s membership
members’ positive and negative experience with the plan’s services
all of the above
>---------- End of the Test ----------<
1 C
2 C
3 A
4 C
5 D

AHM 530 - Tests

Загружено:

Сведения о документе

Исходное описание:

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

AHM 530 - Tests

Загружено:

Авторское право:

Доступные форматы

Assignment 1: The Network Management Function

Reading 1A: The Role of Network Management in a Health Plan Organization

1. Select or enter the best answer for each of the 5 questions.

Complete the Test

2. Decide whether the following statement is true or false:

The organizational structure of a health plan’s network management function Go to

3. The following paragraph contains an incomplete statement. Select the

5. Network managers rely on a health plan’s claims administration

>---------- End of the Test ----------<

1. Select or enter the best answer for each of the 11 questions.

Complete the Test

2. Federal laws—including the Ethics in Patient Referrals Act, the Health

3. In 1996, Congress passed the Health Insurance Portability and

Members of a physician-hospital organization (PHO) denied membership to a

8. In the paragraph below, two statements each contain a pair of terms

9. The National Committee for Quality Assurance (NCQA) has integrated

>---------- End of the Test ----------<

Reading 2A: Analysis of Market and health plan Needs

1. Select or enter the best answer for each of the 8 questions.

Complete the Test

2. The Holiday Health Plan is preparing to enter a new market. In order to

Question 1: What are the cost-containment strategies of the health plans Go to

In its competitive analysis, Holiday should most likely obtain answers to

4. Provider panels can be either narrow or broad. Compared to a similarly Go to

experience higher contracting costs

6. Lakesha Frazier, a member of a health plan in a rural area, had been

7. A population’s demographic factors—such as income levels, age, gender,

8. In developing a provider network in an large city with a high concentration

>---------- End of the Test ----------<

1. Select or enter the best answer for each of the 7 questions.

Complete the Test

The network strategy that Gardenia is using to establish its range of

The following statement(s) can correctly be made about Gardenia’s Go to

1. When establishing its PPO network, Gardenia most likely initiated

2. To avoid high overhead expenses in the early stages of market

4. Health plans are required to follow several regulations and guidelines

5. Some jurisdictions have enacted corporate practice of medicine laws. One Go to

require incorporated HMOs to practice medicine through licensed

7. Before incurring the expense of assembling a new PPO network, the

>---------- End of the Test ----------<

• Define delegation and sub-delegation

1. Select or enter the best answer for each of the 3 questions.

Complete the Test

2. Although a health plan is allowed to delegate many activities to outside

>---------- End of the Test ----------<

1. Select or enter the best answer for each of the 7 questions.

Complete the Test

must be employees of the health plan, rather than independent

3. In open panel contracting, there are several types of delivery systems.

4. The following statement(s) can correctly be made about hospitalists.

1. The hospitalist’s main function is to coordinate diagnostic and treatment

>---------- End of the Test ----------<

1. Select or enter the best answer for each of the 8 questions.

Complete the Test

has a legal right to access a prospective provider’s confidential medical

Applicant 1 has completed his surgical residency, and he recently passed a

Applicant 2 has completed her residency in dermatology, and she is

With regard to these applicants, it can correctly be stated that only

3. The Justice Health Plan is eligible to submit reportable actions against

Action 1—A medical malpractice insurer made a malpractice payment on

a provider’s current, updated application information, as well as

require a medical examination prior to accepting an application for

7. Determine whether the following statement is true or false: