NEW QUESTION 1

The following statements are about workers' compensation provider networks. Select the answer choice containing the correct statement:

• A. In order to supply a provider network to furnish healthcare to workers' compensation beneficiaries, a health plan typically uses the network that has already been created for the group health plan.
• B. Typically, case managers for workers' compensation programs are physical therapists.
• C. Most states prohibit the use of fee schedules in order to curb the rising workers' compensation healthcare costs.
• D. Networks serving workers' compensation patients typically include higher concentrations of specialists than do other provider networks.

Answer: D

NEW QUESTION 2

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service
(DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:

• A. D
• B. Enberg's young patients receive appropriate immunizations at the right ages
• C. D
• D. Enberg's young patients receive appropriate immunizations at the right ages
• E. The condition of one of D
• F. Enberg's patients improved after the patient received medical treatment from D
• G. Enberg
• H. D
• I. Enberg's procedures are adequate for ensuring patients' access to medical care

Answer: A

NEW QUESTION 3

Edward Patillo has established a Medicare+Choice medical savings account (MSA). This MSA will allow Mr. Patillo to:

• A. Carry over any money remaining in his MSA at the end of the benefit year to the next benefit year
• B. Make withdrawals at any time from the MSA, but only for medical expenses
• C. Obtain payment at 100% of the Medicare allowable payment for all Medicare-covered services he receives, without having to pay any deductibles or out-of-pocket expenses
• D. Make withdrawals from the MSA to meet qualified medical expenses that are not paid by his high-deductible health insurance policy, but these withdrawals are taxed as income to M
• E. Patillo

Answer: A

NEW QUESTION 4

During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider’s application. One true statement regarding this process is that the health plan

• A. has a legal right to access a prospective provider’s confidential medical records at any time
• B. 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 physicianaccepts at the end of each day
• C. 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
• D. 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

Answer: D

NEW QUESTION 5

The actual number of providers included in a provider network can be based on staffing ratios. One true statement about staffing ratios is that, typically:

• A. A small health plan needs fewer physicians per 1,000 than does a large plan.
• B. A closely managed health plan requires fewer providers than does a loosely managedplan.
• C. Physician-to-enrollee ratios can be used directly only by network-within-a-network model HMOs.
• D. Medicare products require fewer providers than do employer-sponsored plans of the same size.

Answer: B

NEW QUESTION 6

One characteristic of the workers' compensation program is that:

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

Answer: A

NEW QUESTION 7

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.
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

• A. Receiving workers’ compensation benefits unless he can show that the employer was at fault for his injury
• B. Obtaining care from providers who are not members of a workers’ compensation network
• C. Suing his employer for additional benefits
• D. Claiming benefits from both workers’ compensation and his group health plan

Answer: C

NEW QUESTION 8

The following statements are about incentive programs used for providers. Select the answer choice containing the correct statement.

• A. Risk pools based on aggregate provider performance eliminate problems associated with “free riders.”
• B. A hospital bonus pool is usually split between the health plan and the PCPs.
• C. 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.
• D. For providers, withhold arrangements eliminate the risk of losing base income.

Answer: B

NEW QUESTION 9

The following statement(s) can correctly be made about financial arrangements between health plans and emergency departments of hospitals:

• A. These arrangements typically include payments for services rendered in the emergency department by a health plan's primary or specialty care providers.
• B. Most of these arrangements are structured through the health plan's contract with the hospital.
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: C

NEW QUESTION 10

A population’s demographic factors—such as income levels, age, gender, race, and ethnicity—can influence the design of provider networks serving that population. With respect to these demographic factors, it is correct to say that

• A. higher-income populations have a higher incidence of chronic illnesses than do lowerincome populations
• B. compared to other groups, young men are more likely to be attached to particular providers
• C. a population with a high proportion of women typically requires more providers than does a population that is predominantly male
• D. 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

Answer: C

NEW QUESTION 11

The two basic approaches that Medicaid uses to contract with health plans are open contracting and selective contracting. One true statement about these approaches to contracting is that:

• A. Open contracting requires health plans to meet minimum performance standards outlined in a state's request for proposal (RFP)
• B. Open contracting makes it possible for the Medicaid agency to offer enrollment volume guarantees
• C. Selective contracting requires any health plan that meets the state's performance standards and the federal Medicaid requirements to enter into a Medicaid contract
• D. Selective contracting requires health plans to bid competitively for Medicaid contracts

Answer: D

NEW QUESTION 12

The introductory paragraph of a provider contract is generally followed by a section called the recitals. The recitals section of the contract typically specifies the

• A. Purpose of the agreement
• B. Manner in which the provider is to bill for services
• C. Definitions of key terms to be used in the contract
• D. Rate at which the provider will be compensated

Answer: A

NEW QUESTION 13

The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.
If Gladspell’s per diem contract with Ellysium is typical, then the per diem payment will cover such medical costs as

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

Answer: C

NEW QUESTION 14

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:
Regulation 1: Mosaic must establish a mandated grievance resolution mechanism, including a method for members to address grievances with network providers.
Regulation 2: Mosaic must not allow its providers to refer Medicare and Medicaid patients to entities 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.

• A. Regulation 1 - The Ethics in Patient Referrals Act Regulation 2 - The HMO Act of 1973
• B. Regulation 1 - The HMO Act of 1973 Regulation 2 - The Ethics in Patient Referrals Act
• C. Regulation 1 - ERISA Regulation 2 - The Federal Trade Commission Act
• D. Regulation 1 - The Federal Trade Commission Act Regulation 2 - ERISA

Answer: B

NEW QUESTION 15

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:

• A. D
• B. Kwan most likely was required to seek authorization from Poplar before performing this particular service.
• C. D
• D. Kwan most likely was paid on a FFS basis for providing this service.
• E. Both A and B
• F. A only
• G. B only
• H. Neither A nor B

Answer: D

NEW QUESTION 16

The sizes of the businesses in a market affect the types of health programs that are likely to be purchased. Compared to smaller employers (those with fewer than 100 employees), larger employers (those with more than 1,000 employees) are

• A. more likely to contract with indemnity health plans
• B. more likely to offer their employees a choice in health plans
• C. less likely to contract with health plans
• D. less likely to require a wide variety of benefits

Answer: B

NEW QUESTION 17

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

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

Answer: B

NEW QUESTION 18

One true statement about the Employee Retirement Income Security Act of 1974 (ERISA) is that:

• A. ERISA applies to all issuers of health insurance products, such as HMOs
• B. pension plans and employee welfare plans are exempt from any regulation under ERISA
• C. ERISA requires self-funded plans to comply with all state mandates affecting health insurance companies and health plans
• D. the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plans

Answer: D

NEW QUESTION 19

The actual number of providers included in a provider network may be based on staffing ratios. Staffing ratios relate the number of

• A. Potential providers in a plan’s network to the number of individuals in the area to be served by the plan
• B. Providers in a plan’s network to the number of enrollees in the plan
• C. Providers outside a plan’s network to the number of providers in the plan’s network
• D. Support staff in a plan’s network to the number of medical practitioners in the plan’s network

Answer: B

NEW QUESTION 20
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