NEW QUESTION 1

In most states, workers’ compensation is first-dollar and last-dollar coverage, which means thatworkers’ compensation programs

• A. Can place limits on the benefits they will pay for a given claim
• B. Can deny coverage for work-related illness or injury if the employer is not at fault
• C. Must pay 100% of work-related medical and disability expenses
• D. Can hold employers liable for additional amounts that result from court decisions

Answer: C

NEW QUESTION 2

In order to evaluate and manage the performance of individual providers in its provider network, the Quorum Health Plan implemented a program that focuses on identifying the best and worst outcomes and utilization patterns of its providers. This program is also designed to develop and implement strategies such as treatment protocols and practice guidelines to improve the performance of Quorum's providers. This information indicates that Quorum implemented a program known as:

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

Answer: D

NEW QUESTION 3

Factors that are likely to indicate increased health plan market maturity include:

• A. Increased consolidation among health plans.
• B. Increased rate of growth in health plan premium levels.
• C. Areduction in the market penetration of HMO and point-of-service (POS) products.
• D. Areduction in the frequency of performance-based reimbursement of providers.

Answer: A

NEW QUESTION 4

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

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

Answer: B

NEW QUESTION 5

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 provide all specialty services for Cordelia plan members who are undergoing cancer treatment. In return, Promise receives a capitated amount from Cordelia. Promise is an example of a type of specialty services organization known as a

• A. Specialty IPA
• B. Disease management company
• C. Single specialty management specialist
• D. Specialty network management company

Answer: B

NEW QUESTION 6

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 resources at a much higher rate than does Dr. Donne. In order to equitably compare Dr. Comer’s performance with Dr. Donne’s performance, the health 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. Acase mix/severity adjustment
• B. An external performance standard
• C. Structural measures
• D. Behavior modification

Answer: A

NEW QUESTION 7

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 hospital risk pool at $40 per member per month (PMPM).
If Ionic’s actual 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

• A. $30,000
• B. $270,000
• C. $300,000
• D. $702,000

Answer: B

NEW QUESTION 8

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 with increasing market shares?
Question 2: What are the premium strategies of the health plans with large 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

• A. 1, 2, and 3
• B. 1 and 2 only
• C. 1 and 3 only
• D. 2 and 3 only

Answer: A

NEW QUESTION 9

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

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

Answer: C

NEW QUESTION 10

The following statements can correctly be made about the advantages and disadvantages to an health plan of using the various delivery options for pharmacy services.

• A. A disadvantage of using open pharmacy networks is that the health plan’s control over costs is limited to setting reimbursement levels.
• B. An advantage of using performance-based systems is that they tend to increase participation in the health plan’s pharmacy network.
• C. A disadvantage of using customized pharmacy networks is that these networks typically can be implemented only in companies with fewer than 500 employees.
• D. All of these statements are correct.

Answer: A

NEW QUESTION 11

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

• A. Must provide Medicare participants with standard HMO benefits, as well as with limited long-term care benefits
• B. Does not need as great a variety of provider types or as complex a reimbursement method as does a traditional HMO
• C. Receives a payment that is based on reasonable costs and reasonable charges
• D. Most likely provides fewer supportive services than does a traditional HMO, because one of Bruin's goals is to minimize the use of community-based care

Answer: A

NEW QUESTION 12

The provider contract between the Regal Health Plan and Dr. Caroline Quill contains a type of termination clause known as termination without cause. One true statement about this clause is that it

• A. Requires Regal to send a report to the appropriate accrediting agency if the health plan terminates D
• B. Quill’s contract without cause
• C. Requires that Regal must base its decision to terminate D
• D. Quill’s contract on clinical criteria only
• E. Allows either Regal or D
• F. Quill to terminate the contract at any time, without any obligation to provide a reason for the termination or to offer an appeals process
• G. Allows Regal to terminate D
• H. 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

Answer: C

NEW QUESTION 13

One important aspect of network management is profiling, or provider profiling. Profiling is most often used to

• A. measure the overall performance of providers who are already participants in the network
• B. assess a provider’s overall satisfaction with a plan’s service protocols and other operational areas
• C. verify a prospective provider’s professional licenses, certifications, and training
• D. familiarize a provider with a plan’s procedures for authorizations and referrals

Answer: A

NEW QUESTION 14

The employees of the Trilogy Company are covered by a typical workers' compensation program. Under this coverage, Trilogy employees are bound by the exclusive remedy doctrine, which most likely:

• A. Allows Trilogy to deny benefits for an employee's on-the-job injury or illness, but only if Trilogy is not at fault for the injury or illness.
• B. Allows Trilogy to place limits on the amount of coverage payable for a given claim under the workers' compensation program.
• C. Requires the employees to accept workers' compensation as their only compensation in cases of work-related injury or illness.
• D. Provides the employees with 24-hour coverage.

Answer: C

NEW QUESTION 15

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

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

Answer: B

NEW QUESTION 16

Participating providers in a health plan’s network must undergo recredentialing on a regular basis. During recredentialing, a health plan typically reviews

• A. a provider’s current, updated application information, as well as provider’s peer reviews and performance reports on the provider
• B. a provider’s current, updated application information, as well as the provider’s education and prior work history
• C. a provider’s education and prior work history only
• D. peer reviews and performance reports on a provider and the provider’s prior work history only

Answer: A

NEW QUESTION 17

The provider contract that Dr. Laura Cartier has with the Sailboat health plan includes a section known as the recitals. Dr. Cartier's contract includes the following statements:

• A. A statement that identifies the purpose of the contract
• B. A statement that defines in legal terms the parties to the contract
• C. A statement that identifies the Sailboat products to be covered by the contractOf these statements, the ones that are likely to be included in the recitals section of D
• D. Cartier's contract are statements:
• E. A, B, and C
• F. A and B only
• G. A and C only
• H. B and C only

Answer: A

NEW QUESTION 18

Four types of APCs are ancillary APCs, medical APCs, significant procedure APCs, and surgical APCs. An example of a type of APC known as

• A. An ancillary APC is a biopsy
• B. Amedical APC is radiation therapy
• C. Asignificant procedure APC is a computerized tomography (CT) scan
• D. Asurgical APC is an emergency department visit for cardiovascular disease

Answer: C

NEW QUESTION 19

The Omnibus Budget Reconciliation Act of 1986 (OBRA 1986) established the Programs of All-Inclusive Care for the Elderly (PACE). One characteristic of the PACE programs is that:

• A. They are available to United States citizens only after they reach age 65.
• B. They have an upper dollar limit.
• C. They receive a monthly capitation that is set at 100% of the Adjusted Average Per Capita Cost (AAPCC).
• D. PACE providers receive capitated payments only through the PACE agreement.

Answer: D

NEW QUESTION 20
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