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NO.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.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated
whether:
A. Dr. Enberg's young patients receive appropriate immunizations at the right ages
B. Dr. Enberg's young patients receive appropriate immunizations at the right ages
C. The condition of one of Dr. Enberg's patients improved after the patient received medical
treatment from Dr. Enberg
D. Dr. Enberg's procedures are adequate for ensuring patients' access to medical care
Answer: A
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NO.2 In open panel contracting, there are several types of delivery systems. One such delivery system
is the faculty practice plan (FPP). One likely result that a health plan will experience by contracting
with an FPP is that the health plan will
A. be able to select most of the physicians in the FPP
B. achieve the highest level of cost effectiveness possible
C. experience limited control over utilization
D. achieve the most effective case management possible
Answer: C
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NO.3 One true statement about the compensation arrangement known as the case rate system is
that, under this system,
A. Providers stand to gain or lose based on the number and types of treatments used for each case
B. Providers have no incentives to take an active role in managing cost and utilization
C. Payors cannot adjust standard case rates to reflect the severity of the patient's condition or
complications that arise from multiple medical problems
D. Payors have the opportunity to benefit from the provider's cost savings
Answer: A
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NO.4 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
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NO.5 The Portway Hospital is qualified to receive Medicaid subsidy payments as a disproportionate
share hospital (DHS). The DHS payments that Portway receives are
A. Made for services rendered to specific patients
B. Made with matching state and federal funds
C. Included in the Medicaid capitation payment made to patients' health plans
D. Defined as cost-based reimbursement (CBR) equal to 100% of Portway's reasonable costs of
providing services to Medicaid recipients
Answer: B
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NO.6 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
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NO.7 Dr. Sarah Carmichael is one of several network providers who serve on one of the Apex Health
Plan's organizational committees. The committee reviews cases against providers identified through
complaints and grievances or through clinical monitoring activities. If needed, the committee
formulates, approves, and monitors corrective action plans for providers. Although Apex
administrators and other employees also serve on the committee, only participating providers have
voting rights. The committee that Dr. Carmichael serves on is a
A. Utilization management committee
B. Peer review committee
C. Medical advisory committee
D. Credentialing committee
Answer: B
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NO.8 With regard to the compensation of dental care providers in a managed dental care system, it is
correct to state that, typically:
A. dental PPOs compensate dentists on a capitated basis
B. group model dental HMOs (DHMOs) compensate general dental practitioners on a salaried basis
C. independent practice association (IPA)-model dental HMOs (DHMOs) capitate general dental
practitioners
D. staff model dental HMOs (DHMOs) compensate dentists on an FFS basis
Answer: C
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