Regenerate Network Management AHM-530 Braindumps

NEW QUESTION 1

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 2

Dr. Sylvia Cimer and Dr. Andrew Donne are obstetrician/gynecologists who participate in
the same provider network. Dr. Comer treats a large number of high-risk patients, whereas Dr. Donne’s patients are generally healthy and rarely present complications. As a result, Dr. Comer typically uses medical resources at a much higher rate than does Dr. Donne. In order to equitably compare Dr. Comer’s performance with Dr. Donne’s performance, the health plan modified its evaluation to account for differences in the providers’ patient populations and treatment protocols. The health plan modified Dr. Comer’s and Dr. Donne’s performance data by means of

• A. Acase mix/severity adjustment
• B. An external performance standard
• C. Structural measures
• D. Behavior modification

Answer: A

NEW QUESTION 3

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 reportincluded 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 report that helped Canyon determine how well Dr. Enberg met the health plan's standards is known as:

• A. An encounter report
• B. An external standards report
• C. Aprovider profile
• D. An access to care report

Answer: C

NEW QUESTION 4

In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it

• A. Applies to group health insurance plans only
• B. Limits the length of a health plan’s pre-existing condition exclusion period for a previously covered individual to a maximum of six months after enrollment.
• C. Guarantees access to healthcare coverage for small businesses and previously covered individuals who meet specified eligibility requirements.
• D. Guarantees renewability of group and individual health coverage, provided the insureds are still in good health

Answer: C

NEW QUESTION 5

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 6

Promise, Inc., a corporation that specializes in cancer services, employs its physicians and support staff and provides facilities and ancillary services for cancer patients. Promise has contracted with the Cordelia Health Plan to provide all specialty services for Cordelia plan members who are undergoing cancer treatment. In return, Promise receives a capitated amount from Cordelia. Promise is an example of a type of specialty services organization known as a

• A. Specialty IPA
• B. Disease management company
• C. Single specialty management specialist
• D. Specialty network management company

Answer: B

NEW QUESTION 7

In developing a provider network in an large city with a high concentration of young families, the Gypsum Health Plan has set goals focused on the needs of that particular market. The following statements are about this situation. Three of the statements are true, and one of the statements is false. Select the answer choice that contains the FALSE statement.

• A. Gypsum should attempt to recruit providers who offer extended office hours.
• B. Gypsum can use the cost-effectiveness of its own existing networks as a benchmark for its cost-savings goals in this market.
• C. Gypsum will most likely attempt to contract with HMOs.
• D. Gypsum most likely should set lower cost-savings goals in this market than it would in a rural market with few young families.

Answer: D

NEW QUESTION 8

The employees of the Trilogy Company are covered by a typical workers' compensation program. Under this coverage, Trilogy employees are bound by the exclusive remedy doctrine, which most likely:

• A. Allows Trilogy to deny benefits for an employee's on-the-job injury or illness, but only if Trilogy is not at fault for the injury or illness.
• B. Allows Trilogy to place limits on the amount of coverage payable for a given claim under the workers' compensation program.
• C. Requires the employees to accept workers' compensation as their only compensation in cases of work-related injury or illness.
• D. Provides the employees with 24-hour coverage.

Answer: C

NEW QUESTION 9

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 10

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 11

The following statements describe two types of HMOs:
The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.
The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.
Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.
Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:
The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents
per tablet for this drug.
The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.
From the following answer choices, select the response that best identifies Elm and Treble:

• A. Elm: open access (OA) HMO Treble: direct access HMO
• B. Elm: open access (OA) HMO Treble: gatekeeper HMO
• C. Elm: direct access HMO Treble: open access (OA) HMO
• D. Elm: direct access HMO Treble: gatekeeper HMO

Answer: C

NEW QUESTION 12

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 13

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 14

The Sweeney Health Plan uses the discounted fee-for-service (DFFS) method to compensate some of its providers. Under this method of compensation, Sweeney calculates payments based on

• A. The standard fees of indemnity health insurance plans, adjusted by region
• B. The Medicare fee schedules used by other health plans, adjusted by region
• C. Whichever amount is higher, the billed charge or the DFFS amount
• D. Whichever amount is lower, the billed charge or the DFFS amount

Answer: D

NEW QUESTION 15

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 16

The National Committee for Quality Assurance (NCQA) has integrated accreditation with Health Employer Data and Information Set (HEDIS) measures into a program called Accreditation ’99. One statement that can correctly be made about these accreditation standards is that

• A. Health plans are required by law to report HEDIS results to NCQA
• B. HEDIS restricts its reporting criteria to a narrow group of quantitative performance measures, while NCQA includes a broad range of qualitative performance measures
• C. Private employer groups purchasing health care coverage increasingly require both NCQA accreditation and HEDIS reporting
• D. HEDIS includes measures of a health plan’s effectiveness of care rather than its cost of care

Answer: C

NEW QUESTION 17

The provider contract that Dr. Laura Cartier has with the Sailboat health plan includes a section known as the recitals. Dr. Cartier's contract includes the following statements:

• A. A statement that identifies the purpose of the contract
• B. A statement that defines in legal terms the parties to the contract
• C. A statement that identifies the Sailboat products to be covered by the contractOf these statements, the ones that are likely to be included in the recitals section of D
• D. Cartier's contract are statements:
• E. A, B, and C
• F. A and B only
• G. A and C only
• H. B and C only

Answer: A

NEW QUESTION 18

Network managers rely on a health plan’s claims administration department for much of the information needed to manage the performance of providers who are not under a capitation arrangement. Examining claims submitted to a health plan’s claims administration department enables the health plan to

• A. determine the number of healthcare services delivered to plan members
• B. monitor the types of services provided by the health plan’s entire provider network
• C. evaluate providers’ practice patterns and compliance with the health plan’s procedures for the delivery of care
• D. all of the above

Answer: D

NEW QUESTION 19
......