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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 conforms to standards for prescribing controlled substances
  • 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


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


The following statement(s) can correctly be made about the Balanced Budget Act (BBA) of 1997:

  • A. The BBA requires Medicare+Choice organizations to be licensed as non-risk-bearing entities under federal law.
  • B. The Centers for Medicaid and Medicare Services (CMS) is responsible for implementing the BBA.
  • C. Both A and B
  • D. A only
  • E. B only
  • F. Neither A nor B

Answer: C


The Tuba Health Plan recently underwent an accreditation process under a program known as Accreditation '99, which includes selected Health Employer Data and Information Set (HEDIS) measures. Under Accreditation '99, Tuba received a rating of Excellent. The following statement(s) can correctly be made about this quality assessment of Tuba's operations:

  • A. In arriving at its rating of Excellent for Tuba, the Accreditation '99 program most likely focused on Tuba's demonstrated results and evaluated the processes that Tuba used to achieve those results.
  • B. Tuba is required to report all HEDIS results to the NAIC.
  • C. Both A and B
  • D. A only
  • E. B only
  • F. Neither A nor B

Answer: B


The Argyle Health Plan has contracted to obtain the services of the providers in the Column Medical Group, a faculty practice plan (FPP). The following statement(s) can correctly be made about this contract:

  • A. Column most likely contracted with the legal group representing the FPP rather than with the individual physicians within the FPP.
  • B. Column most likely will provide only highly specialized care to Argyle's plan members.
  • C. Both A and B
  • D. A only
  • E. B only
  • F. Neither A nor B

Answer: B


Dr. Leona Koenig removed the appendix of a plan member of the Helium health plan. In order to increase the level of reimbursement that she would receive from Helium, Dr. Koenig submitted to the health plan separate charges for the preoperative physical examination, the surgicalprocedure, and postoperative care. All of these charges should have been included in the code for the surgical procedure itself. Dr. Koenig's submission is a misuse of the coding system used by health plans and is an example of:

  • A. Upcoding
  • B. A wrap-around
  • C. Churning
  • D. Unbundling

Answer: D


The following situations illustrate violations of federal antitrust laws:
Situation A Two HMOs split a large employer group by agreeing to let one HMO market to some company employees and to let the second HMO market to different company employees.
Situation B Members of a physician-hospital organization (PHO) that has significant market share jointly agreed to exclude a physician from joining the PHO solely because that physician has admitting privileges at a competing hospital.
From the following answer choices, select the response that best identifies the types of violations illustrated by these situations:

  • A. Situation A: horizontal division of territories; Situation B: group boycott
  • B. Situation A: horizontal division of territories; Situation B: exclusive arrangement
  • C. Situation A: exclusive arrangement; Situation B: group boycott
  • D. Situation A: exclusive arrangement; Situation B: tying arrangement

Answer: A


Dr. Janet Dubois is a radiologist who practices exclusively at the Rightway Healthcare Center. This information indicates that Dr. Dubois is employed by Rightway as

  • A. An academic practitioner
  • B. An independent practitioner
  • C. Anetwork manager
  • D. Ahospital-based specialist

Answer: D


The Festival Health Plan is in the process of recruiting physicians for its provider network. Festival requires its network physicians to be board 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

  • A. Applicants 1 and 2 are board certified
  • B. Applicants 2 and 3 are board certified
  • C. Applicant 1 is board certified
  • D. Applicant 3 is board certified

Answer: C


A provider contract describes the responsibilities of each party to the contract. These responsibilities can be divided into provider responsibilities, health plan responsibilities, and mutual obligations. Mutual obligations typically include

  • A. provisions for marketing the plan’s product
  • B. payment arrangements between the plan and the provider
  • C. verification of the plan’s eligibility to do business
  • D. management of the contents of members’ medical records

Answer: B


The Zephyr Health Plan identifies members for whom subacute care might be an appropriate treatment option. The following individuals are members of Zephyr:
Selena Tovar, an oncology patient who requires radiation oncology services, chemotherapy, and rehabilitation.
Dwight Borg, who is in excellent health except that he currently has sinusitis.
Timothy O'Shea, who is beginning his recovery from brain injuries caused by a stroke. Subacute care most likely could be an appropriate option for:

  • A. M
  • B. Tovar, M
  • C. Borg, and M
  • D. O'Shea
  • E. M
  • F. Tovar and M
  • G. O'Shea only
  • H. M
  • I. O'Shea only
  • J. M
  • K. Borg only

Answer: B


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 severe pain) such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate 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

  • A. medical necessity standard
  • B. prudent layperson standard
  • C. “all-or-none” standard
  • D. reasonable and customary standard

Answer: B


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.
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

  • A. 1, 2, and 3 only
  • B. 1 and 3 only
  • C. 2 and 4 only
  • D. 3 and 4 only

Answer: B


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. Apex compensates PCPs for immunizations on a case rate basis.
The Bengal Health Plan carves out behavioral healthcare services from 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.

  • A. Apex: disease-specific carve-out Bengal: specialty services carve-out
  • B. Apex: disease-specific carve-out Bengal: specific-service carve-out
  • C. Apex: specific-service carve-out Bengal: specialty services carve-out
  • D. Apex: specific-service carve-out Bengal: disease-specific carve-out

Answer: C


One true statement about the Medicaid program in the United States is that:

  • A. The federal financial participation (FFP) in a state's Medicaid program ranges from 20% to 40% of the state's total Medicaid costs
  • B. Medicaid regulations mandate specific minimum benefits, under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, for all Medicaid recipients younger than age 30
  • C. The individual states have responsibility for administering the Medicaid program
  • D. Non-disabled adults and children in low-income families account for the majority of direct Medicaid spending

Answer: C


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


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