NEW QUESTION 1

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.
The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan member for covered services is known as:

• A. Atermination with cause clause
• B. Ahold-harmless clause
• C. An indemnification clause
• D. Acorrective action clause

Answer: B

NEW QUESTION 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 other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
Qualitative measures that Azure could use to assess provider performance include an evaluation of how

• A. Quickly the provider responds to plan members’ inquiries
• B. Effectively the provider communicates with plan members
• C. Often the provider refers plan members for ancillary services
• D. Many plan members visit the provider per month

Answer: C

NEW QUESTION 3

Some jurisdictions have enacted corporate practice of medicine laws. One effect that corporate practice of medicine laws have had on HMO provider networks is that these laws typically

• A. require incorporated HMOs to practice medicine through licensed employees
• B. 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
• C. restrict the ability of staff model HMOs to hire physicians directly, unless the physiciansown the HMO
• D. encourage incorporated HMOs to obtain profits from their provisions of physician professional services

Answer: C

NEW QUESTION 4

An health plan enters into a professional services capitation arrangement whenever the health plan

• A. 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
• B. Pays individual specialists to provide only radiology services to all plan members
• C. 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
• D. Contracts with a primary care provider to cover primary care services only

Answer: A

NEW QUESTION 5

Health plans use a variety of sources to find candidates to recruit for their provider networks. In general, two of the most effective methods of finding candidates are through

• A. Word of mouth and on-site training programs
• B. Word of mouth and direct mail
• C. Advertisements in local newspapers and on-site training programs
• D. Advertisements in local newspapers and direct mail

Answer: B

NEW QUESTION 6

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

• A. Ideally, a health plan should have every specialist category represented on its provider panel with appropriate geographic distribution.
• B. Most specialist contracts do not ensure the provider’s adherence to UM policies set up by the health plan.
• C. No-balance-billing clauses are not desirable in health plan contracts with specialists.
• D. In geographic regions where there is a shortage of PCPs, a health plan is not permitted to contract with specialists to perform primary care services, even for patients with chronic conditions.

Answer: A

NEW QUESTION 7

For this question, if answer choices (A) through C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Understanding the level of health plan penetration in a particular market can help a health plan determine which products are most appropriate for that market. Indicators of a mature health plan market include

• A. Areduction in the rate of growth in health plan premium levels
• B. Areduction in the level of outcomes management and improvement
• C. An increase in the rate of inpatient hospital utilization
• D. All of the above

Answer: A

NEW QUESTION 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.
In most states, a health plan can be held responsible for a provider’s 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).

• A. Vicarious liability / employees of the health plan
• B. Vicarious liability / independent contractors
• C. Risk sharing / employees of the health plan
• D. Risk sharing / independent contractors

Answer: B

NEW QUESTION 9

Dr. Eve Barlow is a specialist in the Amity Health Plan’s provider network. Dr. Barlow’s provider contract with Amity contains a typical most-favored-nation arrangement. The purpose of this arrangement is to

• A. Require D
• B. Barlow and Amity to use arbitration to resolve any disputes regarding the contract
• C. Specify that the contract is to be governed by the laws of the state in which Amity has its headquarters
• D. Require D
• E. 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
• F. State that the contract creates an employment or agency relationship, rather than an independent contractor relationship, between D
• G. Barlow and Amity

Answer: C

NEW QUESTION 10

Member satisfaction surveys help an health plan determine whether its providers are consistently delivering services to plan members in a manner that lives up to member expectations. Member satisfaction surveys allow the health plan to gather information about

• A. Amember’s reaction to services received during a specific encounter
• B. The reactions of specific subsets of the health plan’s membership
• C. Members’ positive and negative experience with the plan’s services
• D. All of the above

Answer: D

NEW QUESTION 11

The Aegean Health Plan delegated its utilization management (UM) program to the Silhouette IPA. Silhouette, in turn, transferred authority for case management to Brandon Health Services. In this situation, Brandon is best described as the

• A. delegator, and Aegean is ultimately responsible for Brandon’s performance
• B. delegator, and Silhouette is ultimately responsible for Brandon’s performance
• C. subdelegate, and Aegean is ultimately responsible for Brandon’s performance
• D. subdelegate, and Silhouette is ultimately responsible for Brandon’s performance

Answer: C

NEW QUESTION 12

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) The Baxter Managed Behavioral Healthcare Organization (MBHO) The Cheshire Dental Health Maintenance Organization (DHMO)
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

• A. Apex and Baxter only
• B. Apex and Cheshire only
• C. Baxter and Cheshire only
• D. Baxter only

Answer: D

NEW QUESTION 13

Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in

• A. Slower access to BH care for plan members
• B. Increased collaboration between BH providers and PCPs
• C. Fewer specialized BH services for plan members
• D. Decreased continuity of BH care for plan members

Answer: D

NEW QUESTION 14

A health plan has several options for delivering pharmacy services to its subscribers. Each option has potential advantages to a health plan. An advantage to a health plan of using:

• A. performance-based open networks is that they tend to increase participation in the pharmacy network.
• B. closed networks is that they improve the health plan's ability to set standards and implement cost-control programs for pharmacy services.
• C. customized networks is that they typically are inexpensive to operate.
• D. open networks is that they tend to improve the health plan's ability to control pharmaceutical costs.

Answer: B

NEW QUESTION 15

Although a health plan is allowed to delegate many activities to outside sources, the National Committee for Quality Assurance (NCQA) has determined that some activities are not delegable.
These activities include

• A. evaluation of new medical technologies
• B. overseeing delegated medical records activities
• C. developing written statements of members’ rights and responsibilities
• D. all of the above

Answer: D

NEW QUESTION 16

Since 1981, states have had the option to experiment with new approaches to their Medicaid programs under the “freedom of choice” waivers. Under one such waiver, a Section 1915(b) waiver, states are allowed to

• A. Give Medicaid recipients complete freedom in choosing healthcare providers
• B. Give Medicaid recipients the option to choose not to enroll in a healthcare plan
• C. Mandate certain categories of Medicaid recipients to enroll in health plans
• D. Establish demonstration projects to test new approaches for delivering care to Medicaid recipients

Answer: C

NEW QUESTION 17

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

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

Answer: D

NEW QUESTION 18

Partial capitation is one common approach to capitation. One typical characteristic of partial capitation is that it:

• A. Includes only primary care services
• B. Covers such services as immunizations and laboratory tests
• C. Can be used only if the provider's panel size is less than 50 providers
• D. Covers such services as cardiology and orthopedics

Answer: A

NEW QUESTION 19

In contracting with providers, a health plan can use a closed panel or open panel approach. One statement that can correctly be made about an open panel health plan is that the participating providers

• A. must be employees of the health plan, rather than independent contractors
• B. are prohibited from seeing patients who are members of other health plans
• C. typically operate out of their own offices
• D. operate according to their own standards of care, rather than standards of care established by the health plan

Answer: C

NEW QUESTION 20
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