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TESTED 24 Nov 2024
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The following organizations are the primary sources of accreditation of healthcare organizations:
The Courtland PPO maintains computerized records that include clinical, demographic, and administrative data about individual plan members. The data in these records is available to plan providers, ancillary service departments, pharmacies, and others inv
One of the most influential pieces of legislation in the advancement of managed care within the United States was the HMO Act of 1973. One provision of the HMO Act of 1973 was that it
Which of the following features differentiates a 'Clinic without walls1 from a consolidated medical group?
The statements below describe technology used by two health plans to respond to incoming telephone calls:
The following statements are about standards set forth in the Quality Improvement System for Managed Care (QISMC), established by the Health Care Financing Administration (HCFA, now known as the Centers for Medicare and Medicaid Services).
The Granite Health Plan is a coordinated care plan (CCP) that participates in the Medicare+Choice program. This information indicates that Granite
The Robust Health Plan sometimes uses prospective experience rating to calculate the premiums for a group. Under prospective experience rating, Robust most likely will:
In 1999, the United States Congress passed the Financial Services Modernization Act, referred to as the Gramm-Leach-Bliley (GLB) Act. The primary provisions included under the GLB Act require financial institutions, including health plans, to take several
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy
All CDHP products provide federal tax advantages while allowing consumers to save money for their healthcare.
Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. Specialty services that have certain characteristics are generally good candidates for health pl
Ian Vladmir wants to have a routine physical examination to ascertain that he is in good health. Mr. Vladmir is a member of a health plan that will allow him to select the physician of his choice, either from within his plan's network or from outside of h
Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.
A health plan may use one of several types of community rating methods to set premiums for a health plan. The following statements are about community rating. Select the answer choice containing the correct statement.
In 1999, the United States Congress passed the Financial Services Modernization Act, which is referred to as the Gramm-Leach-Bliley (GLB) Act. The following statement(s) can correctly be made about this act:
In the following sections, we will describe some of the measures health plans use to evaluate the quality of the services and healthcare they offer their members.
Which of the following is the best description of what a 'Process measure' evaluates?
Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. The primary purpose of this clause is to:
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
Following a report by the Institute of Medicine on the incidence and consequences of medical errors, a national task force recommended implementation of a nationwide mandatory system of collecting, analyzing, and reporting standardized information about m
Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Whenever Mr. Murray receives a health claim from a plan member, he reviews the claim
In order to measure the expenses of institutional utilization, Holt Healthcare Group uses the standard formula to calculate hospital bed days per 1,000 plan members per year. On October 23, Holt used the following information to calculate the bed days per
By definition, the marketing process of defining a certain place or market niche for a product relative to competitors and their products and then using the marketing mix to attract certain market segments is known as
Ashley Martin is covered by a managed healthcare plan that specifies a $300 deductible and includes a 30% coinsurance provision for all healthcare obtained outside the plan’s network of providers. In 1998, Ms. Martin became ill while she was on vacation,
In order to cover some of the gap between FFS Medicare coverage and the actual cost of services, beneficiaries often rely on Medicare supplements. Which of the following statements about Medicare supplements is correct?
In preparation for its expansion into a new service area, the Regal MCO is meeting with Dr. Nancy Buhner, a cardiologist who practices in Regal's new service area, in order to convince her to become one of the plan's participating providers. As part of the
A health plan's ability to establish an effective provider network depends on the characteristics of the proposed service area and the needs of proposed plan members. It is generally correct to say that
Bill the member for the balance of the fee above the maximum allowable amount under the fee schedule reimbursement method
The following statements describe individuals who are applying for individual health insurance coverage:
Six months ago, Wilbur Lee lost his health insurance coverage due to a reduction in work hours and has exhausted his coverage under COBRA. Mr. Lee has
The following statement(s) can correctly be made about electronic data interchange (EDI):
Which of the choices below contains the four tools used by marketers that make up the 'promotion mix'?
The Internal Revenue Service has ruled that an HDHP coupled with an HSA may cover certain types of preventive care without a deductible or with a lower amount than the annual deductible applicable to all other services. According to IRS guidance, which on
The main purpose of the Health Plan Employer Data and Information Set (HEDIS) is to provide
Which of the following is NOT a factor that is used by MCOs to determine which services will undergo utilization review?
The following statements apply to health reimbursement arrangements. Select the answer choice that contains the correct statement.
The following statements are about issues associated with marketing healthcare plans to small groups and large groups. Select the answer choice that contains the correct statement.
Each time a patient visits a provider he has to pay a fixed dollar amount?
Keith Murray is a 45 year old chartered accountant & is employed in Livingstone consultancy firm. He has been paying payroll taxes for the past 15 years. Which of the following statements is true regarding Medicare Part A entitlement?
The Links Company, which offers its employees a self-funded health plan, signed a contract with a third party administrator (TPA) to administer the plan. The TPA handles the group's membership services and claims administration. The contract between Links
The Oriole MCO uses a typical diagnosis-related groups (DRGs) payment method to reimburse the Isle Hospital for its treatment of Oriole members. Under the DRG payment method, whenever an Oriole member is hospitalized at Isle, Oriole pays Isle
One HMO model can be described as an extension of a group model HMO because it contracts with multiple group practices, rather than with a single group practice. This HMO model is known as the
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 containing the two terms that you have chosen. For providers, (operational /
Katrina Lopez is a claims analyst for a health plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Ms. Lopez reviewed a health claim for answers to the following questions:
Question A —
One true statement regarding ethics and laws is that the values of a community are reflected in
Patrick Flaherty's employer has contracted to receive healthcare for its employees from the Abundant Healthcare System. Mr. Flaherty visits his primary care physician (PCP), who sends him to have some blood tests. The PCP then refers Mr. Flaherty to a special
Ronald Canton is a member of the Omega MCO. He receives his nonemergency medical care from Dr. Kristen High, an internist. When Mr. Canton needed to visit a cardiologist about his irregular heartbeat, he first had to obtain a referral from Dr. High to see
PBM plans operate under several types of contractual arrangements. Under one contractual arrangement, the PBM plan and the employer agree on a target cost per employee per month. If the actual cost per employee per month is greater than the target cost, t
More procedures or services may be fully covered within the PPO network than those out of network.
The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to be
Members who qualify to participate in a health plan's case management program are typically assigned a case manager. During the course of the member's treatment, the case manager is responsible for
One device that PBM plans use to manage both the cost and use of pharmaceuticals is a formulary. A formulary is defined as
TESTED 24 Nov 2024