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AHM-530
Network Management Questions and Answers

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Questions # 1:

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.

One statement that can correctly be made about Gardenia’s two-level POS product is that

Options:

members who self-refer without first seeing their PCPs will receive no benefits

both Gardenia and the PCPs stand to benefit if the non-provider panels are kept relatively narrow

members will pay higher coinsurance or copayments if they first see their PCPs each time

the plan offers no financial incentives to members to choose an in-network specialist over a non-network specialist

Answer

Questions # 2:

With respect to hiring practices, one step that a health plan most likely can take to avoid violating the terms of the Americans with Disabilities Act (ADA) is to

Options:

Require a medical examination prior to accepting an application for employment

Include in the employment application questions pertaining to health status

Make a conditional offer of employment, and then require the candidate to have an examination prior to granting specific staff privileges

Require applicants to answer questions pertaining to the use of drugs and alcohol

Answer

Questions # 3:

One reimbursement method that health plans can use for hospitals is the ambulatory payment classifications (APCs) method. APCs bear a resemblance to the diagnosis-related groups (DRGs) method of reimbursement. However, when comparing APCs and DRGs, one of the primary differences between the two methods is that only the APC method

Options:

is typically used for outpatient care

assigns a single code for treatment

applies to treatment received during an entire hospital stay

is considered to be a retrospective payment system

Answer

Questions # 4:

Open panel health plans can contract with individual providers or with various provider groups when developing their networks. The following statements are about factors that an open panel health plan might consider in contracting with different types of provider organizations. Select the answer choice that contains the correct statement.

Options:

One limitation of contracting with multispecialty groups is that a health plan obtains only specialty consultants, but not PCPs.

One benefit to a health plan in contracting with an integrated delivery system (IDS) is the ability to have a network in rapid order and to enter into a new market or one that is already competitive.

A health plan that contracts with an individual practice association (IPA) has a greater ability to select and deselect individual physicians than when contracting directly with the providers.

A health plan that contracts with an IDS is able to eliminate the antitrust risk that exists when contracting with an IPA.

Answer

Questions # 5:

If the Oconee Health Plan reimburses its specialty care physicians (SCPs) under a typical retainer method, then Oconee pays SCPs

Options:

Aseparate amount for each service provided, and the payment amount is based solely on a resource-based relative value scale (RBRVS)

Aspecified fee that remains the same regardless of how much or how little time or effort is spent on the medical service performed

Aset amount each month, and Oconee reconciles its payment at periodic intervals on the basis of actual utilization

Aset amount of cash equivalent to a defined time period’s expected reimbursable charges

Answer

Questions # 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).

Options:

Vicarious liability / employees of the health plan

Vicarious liability / independent contractors

Risk sharing / employees of the health plan

Risk sharing / independent contractors

Answer

Questions # 7:

From the following answer choices, choose the type of clause or provision described in this situation.

The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.

Options:

Cure provision

Hold-harmless provision

Evergreen clause

Exculpation clause

Answer

Questions # 8:

Health plans are required to follow several regulations and guidelines regarding the access and adequacy of their provider networks. The Federal Employee Health Benefits Program (FEHBP) regulations, for example, require that health plans

Options:

Allow members direct access to OB/GYN services

Allow members direct access to prescription drug services

Provide access to Title X family-planning clinics

Provide average office waiting times of no more than 30 minutes for appointments with plan providers

Answer

Questions # 9:

The provider contract between the Ocelot Health Plan and Dr. Enos Zorn, one of the health plan’s participating providers, is a brief contract which includes, by reference, an Ocelot provider manual. This manual contains much of the information found in Ocelot’s comprehensive provider contracts. The following statements are about Dr. Zorn’s provider contract. Select the answer choice containing the correct statement.

Options:

All statements in the provider contract shall be deemed to be warranties, because all statements of facts contained in the contract must be true only in those respects material to the contract.

Because the provider manual is part of the contract, Ocelot must make sure that its provider manual is comprehensive and up-to-date.

Because the provider contract is a brief contract, Ocelot most likely is prohibited from amending the contract unilaterally, even if it gives Dr. Zorn advance notice of its intent to amend the contract.

Areas that should be covered in the provider manual, and not in the body of the contract, include any specific legal issues relevant to the contract.

Answer

Questions # 10:

The Octagon Health Plan includes a typical indemnification clause in its provider contracts. The purpose of this clause is to require Octagon’s network providers to

Options:

Agree not to sue or file claims against an Octagon plan member for covered services

Reimburse Octagon for costs, expenses, and liabilities incurred by the health plan as a result of a provider’s actions

Maintain the confidentiality of the health plan’s proprietary information

Agree to accept Octagon’s payment as payment in full and not to bill members for anything other than contracted copayments, coinsurance, or deductibles

Answer

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