Network Management v4.0 (AHM-530)

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Total 210 questions

The NPDB specifies the entities that are eligible to request information from the data bank, as well as the conditions under which requests are allowed. In general, entities that are eligible to request information from the NPDB include

  • A. medical malpractice insurers and the general public
  • B. medical malpractice insurers and professional societies that are screening applicants for membership
  • C. the general public and state licensing boards
  • D. state licensing boards and professional societies that are screening applicants for membership


Answer : D

The Walton Health Plan uses the fee-for-service pharmaceutical reimbursement approach known as the maximum allowable cost (MAC) method. If Waltons MAC list specifies a cost of 8 cents per tablet for a particular drug but the participating pharmacy pays 10 cents per tablet for the drug, then Walton will be obligated to reimburse the pharmacy for

  • A. 8 cents per tablet, but the pharmacy can bill the subscriber for the remaining 2 cents per tablet
  • B. 8 cents per tablet, and the pharmacy cannot bill the subscriber for the remaining 2 cents per tablet
  • C. 10 cents per tablet, but the pharmacy must refund the extra 2 cents per tablet to the subscriber
  • D. 10 cents per tablet, and the pharmacy is not required to refund the extra 2 cents per tablet to the subscriber


Answer : B

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 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 Gardenias establishment of the
PPO and the staff model HMO in its new market:
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, Gardenias
HMO most likely contracted with specialists and ancillary providers until the plans membership grew to a sufficient level to justify employing these specialists.

  • A. Both 1 and 2
  • B. Neither 1 nor 2
  • C. 1 Only
  • D. 2 Only


Answer : D

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 physicians own the HMO
  • D. encourage incorporated HMOs to obtain profits from their provisions of physician professional services


Answer : C

Provider panels can be either narrow or broad. Compared to a similarly sized health plan that uses a broad provider panel, a health plan that uses a narrow provider panel most likely can expect to

  • A. Experience higher contracting costs
  • B. Encounter increased difficulty in utilization management
  • C. Have to charge higher health plan premiums
  • D. Experience lower provider relations costs


Answer : D

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

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 Dr. Quills contract without cause
  • B. Requires that Regal must base its decision to terminate Dr. Quills contract on clinical criteria only
  • C. 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
  • D. Allows Regal to terminate Dr. Quills 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

Decide whether the following statement is true or false:
The organizational structure of a health plans network management function often depends on the size and geographic scope of the health plan. With 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.

  • A. True
  • B. False


Answer : B

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

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement.
One important activity within the scope of network management is ensuring the quality of the health plans provider networks. A primary purpose of __________________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plans preestablished criteria for participation in the network.

  • A. authorization
  • B. provider relations
  • C. credentialing
  • D. utilization management


Answer : C

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 plans 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 plans 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

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 Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The services she actually provided represented an intermediate level of service. Dr. Sandersons action is an example of a type of false billing procedure known as

  • A. Cost shifting
  • B. Churning
  • C. Unbundling
  • D. Upcoding


Answer : D

An health plans contract negotiation team consists of several skilled individuals from different areas. At least one of the members is responsible for evaluating the wording of specific clauses to ensure that the health plans rights are protected, as well as to ensure that the contract is in compliance with state and federal regulation. By profession, this member of the contract negotiation team is typically

  • A. Amedical director
  • B. An attorney
  • C. Afinancial manager
  • D. Aclaims manager


Answer : B

After HIPAA was enacted, Congress amended the law to include the Mental Health Parity
Act (MHPA) of 1996, a federal requirement relating to mental health benefits. One true statement about the MHPA is that it

  • A. requires all health plans to provide coverage for mental health services
  • B. requires health plans to carve out mental/behavioral healthcare from other services provided by the plans
  • C. allows health plans to require patients receiving mental health services to pay higher copayments than patients seeking treatment for physical illnesses
  • D. prohibits health plans that offer mental health benefits from applying more restrictive limits on coverage for mental illness than on coverage for physical illness


Answer : D

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 plans 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 plans network to the number of medical practitioners in the plans network


Answer : B

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Total 210 questions