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AHIP AHM-530 Network Management Exam Practice Test

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Total 202 questions

Network Management Questions and Answers

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Question 1

The Edgewood Health Plan uses a combination of structural, process, outcomes, and customer satisfaction measures to evaluate its network providers’ performance. Edgewood would correctly use outcomes measures to evaluate a provider’s

Options:

A.

Compliance with specific regulatory or accrediting requirement

B.

Appropriate use of specified procedures

C.

Patient progress following treatment

D.

Patient perceptions about how well the provider addresses medical problems

Question 2

Under the compensation arrangement that the Falcon Health Plan has with some of its providers, Falcon holds back 10% of the negotiated payments to these providers in order to offset or pay for any claims that exceed the budgeted costs for referral or hospital services. If the providers keep costs within the budgeted amount, Falcon distributes to them the entire amount of money held back. This way of motivating providers to control costs while providing high-quality, appropriate care is known as a:

Options:

A.

Risk pool arrangement

B.

Withhold arrangement

C.

Cost-shifting arrangement

D.

Bonus pool arrangement

Question 3

The vision benefits offered by the Omni Health Plan include clinical eye care only. The following statements describe vision care received by Omni plan members:

• Brian Pollard received treatment for a torn retina he suffered as a result of an accident

• Angelica Herrera received a general eye examination to test her vision

• Megan Holtz received medical services for glaucoma

Of these medical services, the ones that most likely would be covered by Omni's vision coverage would be the services received by:

Options:

A.

Mr. Pollard, Ms. Herrera, and Ms. Holtz

B.

Mr. Pollard and Ms. Herrera only

C.

Mr. Pollard and Ms. Holtz only

D.

Ms. Herrera and Ms. Holtz only

Question 4

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.

The following statements can correctly be made about the reimbursement for Drugs A and B under the MAC pricing system:

Options:

A.

Treble most likely is obligated to reimburse Manor 14 cents per tablet for Drug A.

B.

Manor most likely is allowed to bill the subscriber 2 cents per tablet for Drug A.

C.

Treble most likely is obligated to reimburse Manor 5 cents per tablet for Drug B.

D.

All of the above statements are correct.

Question 5

Dr. Michelle Kubiak has contracted with the Gem Health Plan, a Medicare+Choice health plan, to provide medical services to Gem's enrollees. Gem pays Dr. Kubiak $40 per enrollee per month for providing primary care. Gem also pays her an additional $10 per enrollee per month if the cost of referral services falls below a targeted level. This information indicates that, according to the substantial financial risk formula, Dr. Kubiak's referral risk under this contract is equal to:

Options:

A.

20%, and therefore this arrangement puts her at substantial financial risk

B.

20%, and therefore this arrangement does not put her at substantial financial risk

C.

25%, and therefore this arrangement puts her at substantial financial risk

D.

25%, and therefore this arrangement does not put her at substantial financial risk

Question 6

Assume that the national average cost per covered employee for PPO rental networks is $3 per member per month (PMPM) and that the average monthly healthcare premium PMPM is $300. This information indicates that, if the number of health plan members is 10,000, then the annual network rental cost to the health plan would be:

Options:

A.

$30,000

B.

$360,000

C.

$9,000,000

D.

$12,000,000

Question 7

One true statement about the responsibilities of providers under typical provider contracts is that most provider contracts:

Options:

A.

include a clause which states that providers must maintain open communications with patients regarding appropriate treatment plans, unless the services are not covered by the member's health plan

B.

hold that the responsibility of the provider to deliver services is usually subject to the provider's receipt of information regarding the eligibility of the member

C.

contain a gag clause or a gag rule

D.

include a clause that explicitly places the responsibility for medical care on the health plan rather than on the provider of medical services

Question 8

The following statement(s) can correctly be made about contracting and reimbursement of specialty care physicians (SCPs):

Options:

A.

Typically, a health plan should attempt to control utilization of SCPs before attempting to place these providers under a capitation arrangement.

B.

Forms of specialty physician reimbursement used by health plans include a retainer and a bundled case rate.

C.

Both A and B

D.

A only

E.

B only

F.

Neither A nor B

Question 9

Health plans typically conduct two types of reviews of a provider's medical records: an evaluation of the provider's medical record keeping (MRK) practices and a medical record review (MRR). One true statement about these types of reviews is that:

Options:

A.

An MRK covers the content of specific patient records of a provider.

B.

The NCQA requires an examination of MRK with all of a health plan's office evaluations.

C.

An MRR includes a review of the policies, procedures, and documentation standards the provider follows to create and maintain medical records.

D.

The NCQA requires MRR for both credentialing and recredentialing of providers in a health plan's network.

Question 10

Stop-loss insurance is designed to protect physicians who face substantial financial risk as a result of physician incentive plans. Medicare + Choice health plans must ensure that a physician has adequate stop-loss protection if the

Options:

A.

physician has a patient panel that exceeds 25,000 patients

B.

physician receives a bonus that is based solely on quality of care, patient satisfaction, or physician participation

C.

difference between the physician’s maximum potential payments and his or her minimum potential payments is less than 25% of the maximum potential payments

D.

physician is subject to a withhold that is greater than 25% of his or her potential payments

Question 11

The Foxfire Health Plan, which has 20,000 members, contracts with dermatologists on a contact capitation basis. The contact capitation arrangement has the following features:

Foxfire distributes the money in the contact capitation fund once each quarter and the distribution is based on the point totals accumulated by each dermatologist.

Foxfire's per member per month (PMPM) capitation for dermatology services is $1.

The dermatologist receives 1 point for each new referral that is not classified as a complicated referral and 1.5 points for each new referral that is classified as complicated.

During the first quarter, Foxfire's PCPs made 450 referrals to dermatologists and 100 of these referrals were classified as complicated. One dermatologist, Dr. Shareef Rashad, received 42 of these referrals; 6 of his referrals were classified as complicated. Statements that can correctly be made about Foxfire's contact capitation arrangement include:

Options:

A.

that the value of each referral point for the first quarter was $120

B.

that the value of Foxfire's contact capitation fund for dermatologists for the first quarter was $20,000

C.

that the payment that Foxfire owed Dr. Rashad for the first quarter was $6,120

D.

all of the above

Question 12

Before or during the orientation process, health plans generally provide new network providers with a provider manual. One of the primary purposes of the provider manual is to

Options:

A.

Provide a directory of contracted providers

B.

Help providers and their staffs develop methods of improving the operation of their practices

C.

Provide feedback to providers regarding their performance

D.

Reinforce and document contractual provisions

Question 13

Member satisfaction surveys help an health plan determine whether its providers are consistently delivering services to plan members in a manner that lives up to member expectations. Member satisfaction surveys allow the health plan to gather information about

Options:

A.

Amember’s reaction to services received during a specific encounter

B.

The reactions of specific subsets of the health plan’s membership

C.

Members’ positive and negative experience with the plan’s services

D.

All of the above

Question 14

The provider contract that Dr. Nick Mancini has with the Utopia Health Plan includes a clause that requires Utopia to reimburse Dr. Mancini on a fee-for-service (FFS) basis until 100 Utopia members have selected him as their primary care provider (PCP). At that time, Utopia will begin reimbursing him under a capitated arrangement. This clause in Dr. Mancini's provider contract is known as:

Options:

A.

an antidisparagement clause

B.

a low-enrollment guarantee clause

C.

a retroactive enrollment changes clause

D.

an eligibility guarantee clause

Question 15

The following statements are about the organization of network management functions of health plans. Select the answer choice containing the correct response:

Options:

A.

Compared to a large health plan, a small health plan typically has more integration among its network management activities and less specialization of roles.

B.

It is usually more efficient to have a large health plan's provider relations representatives located in the health plan's corporate headquarters rather than based in regional locations that are close to the provider offices the representatives cover.

C.

An health plan's provider relations representatives are usually responsible for conducting an initial orientation of providers and educating providers about health plan developments, rather than recruiting and assisting with the selection of new providers.

D.

In general, a health plan that uses a centralized approach for some of its network management activities should not use a decentralized approach for other network management activities.

Question 16

When the Rialto Health Plan determines which of the emergency services received by its plan members should be covered by the health plan, it is guided by a standard which describes emergencies as medical conditions manifesting themselves by acute symptoms of sufficient severity (including severe pain) such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy. This standard, which was adopted by the NAIC in 1996, is referred to as the

Options:

A.

medical necessity standard

B.

prudent layperson standard

C.

“all-or-none” standard

D.

reasonable and customary standard

Question 17

The following statements are about factors that health plans should consider as they develop provider networks in rural and urban markets. Three of the statements are true, and one of the statements is false. Select the answer choice that contains the FALSE statement.

Options:

A.

Compared to providers in urban areas, providers in rural areas are less likely to offer discounts to health plans in exchange for directed patient volume.

B.

In urban areas, limiting the number of specialists on a panel usually affects the network’s market appeal more than does limiting the number of primary care physicians.

C.

The greatest opportunity to create competition in rural areas is among the specialty providers in other nearby communities.

D.

Typically, hospital contracting is easier in urban areas than in rural areas.

Question 18

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

Options:

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

Question 19

The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline.

Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn’s PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn’s dermatology services fund for the first quarter was $15,000. During the quarter, Autumn’s PCPs made 90 referrals, and 20 of these referrals were classified as complicated.

Autumn’s method of reimbursing specialty providers can best be described as a

Options:

A.

Disease-specific arrangement

B.

Contact capitation arrangement

C.

Risk adjustment arrangement

D.

Withhold arrangement

Question 20

Dr. Eve Barlow is a specialist in the Amity Health Plan’s provider network. Dr. Barlow’s provider contract with Amity contains a typical most-favored-nation arrangement. The purpose of this arrangement is to

Options:

A.

Require Dr. Barlow and Amity to use arbitration to resolve any disputes regarding the contract

B.

Specify that the contract is to be governed by the laws of the state in which Amity has its headquarters

C.

Require Dr. Barlow to charge Amity her lowest rate for a medical service she has provided to an Amity plan member, even if the rate is lower than the price negotiated in the contract

D.

State that the contract creates an employment or agency relationship, rather than an independent contractor relationship, between Dr. Barlow and Amity

Question 21

The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.

The per diem reimbursement method will require Gladspell to pay Ellysium a

Options:

A.

Fixed rate for each day a plan member is treated in Ellysium’s subacute care facility

B.

Discounted charge for all subacute care services given by Ellysium

C.

Rate that varies depending on patient category

D.

Fixed rate per enrollee per month

Question 22

In most health plan pharmacy networks, the cost component of the reimbursement formula is based on the average wholesale price (AWP). One true statement about the AWP for prescription drugs is that

Options:

A.

AWPs tend to vary widely from region to region of the United States

B.

The AWP is often substantially higher than the actual price the pharmacy pays for prescription drugs

C.

A health plan’s contracted reimbursement to a pharmacy for prescription drugs is typically the AWP plus a percentage, such as 5%

D.

The AWP usually is lower than the estimated acquisition cost (EAC) for most prescription drugs

Question 23

The following statements are about some of the issues surrounding the contractual responsibilities of health plans. Select the answer choice containing the correct statement.

Options:

A.

Typically, health plans are required to pay completed claims within 10 days of submission.

B.

Health plans typically are prohibited from examining the financial soundness of a self-funded employer plan that relies on the health plan to pay providers for services received by the plan’s members.

C.

Patient delivery is one of the most significant factors that health plans consider when determining whether provider services should be reimbursed on a capitated or fee-for-service (FFS) basis.

D.

Health plans require all providers to agree to an exclusive provider contract.

Question 24

One true statement about the compensation arrangement known as the case rate system is that, under this system,

Options:

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

Question 25

During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider’s application. One true statement regarding this process is that the health plan

Options:

A.

has a legal right to access a prospective provider’s confidential medical records at any time

B.

must limit any evaluations of a prospective provider’s office to an assessment of quantitative factors, such as the number of double-booked appointments a physicianaccepts at the end of each day

C.

is prohibited by law from conducting primary verification of such data as a prospective provider’s scope of medical malpractice insurance coverage and federal tax identification number

D.

must complete the credentialing process before a provider signs the network contract or must include in the signed document a provision that the final contract is contingent upon the completion of the credentialing process

Question 26

In contracting with providers, a health plan can use a closed panel or open panel approach. One statement that can correctly be made about an open panel health plan is that the participating providers

Options:

A.

must be employees of the health plan, rather than independent contractors

B.

are prohibited from seeing patients who are members of other health plans

C.

typically operate out of their own offices

D.

operate according to their own standards of care, rather than standards of care established by the health plan

Question 27

One reason that an health plan would want to use the actual acquisition cost (AAC) pricing system to calculate its drug costs is that, of the systems commonly used to calculate drug costs, the AAC system

Options:

A.

Provides the lowest level of cost for the health plan

B.

Most closely represents what pharmacies are actually charged for prescription drugs

C.

Offers the best control over multiple-source pharmaceutical products

D.

Is the least expensive pricing system for the health plan to implement

Question 28

With respect to contractual provisions related to provider-patient communications, nonsolicitation clauses prohibit providers from

Options:

A.

Encouraging patients to switch from one health plan to another

B.

Disclosing confidential information about the health plan’s reimbursement structure

C.

Dispersing confidential financial information regarding the health plan

D.

Discussing alternative treatment plans with patients

Question 29

The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline.

Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn’s PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn’s dermatology services fund for the first quarter was $15,000. During the quarter, Autumn’s PCPs made 90 referrals, and 20 of these referrals were classified as complicated.

In determining the first quarter payment to dermatologists, Autumn would accurately calculate the value of each referral point to be

Options:

A.

$111.11

B.

$125.00

C.

$150.00

D.

$166.67

Question 30

The provider contract that Dr. Huang Kwan has with the Poplar Health Plan includes a typical scope of services provision. The medical service that Dr. Kwan provided to Alice Meyer, a Poplar plan member, is included in the scope of services. The following statement(s) can correctly be made about this particular medical service:

Options:

A.

Dr. Kwan most likely was required to seek authorization from Poplar before performing this particular service.

B.

Dr. Kwan most likely was paid on a FFS basis for providing this service.

C.

Both A and B

D.

A only

E.

B only

F.

Neither A nor B

Page: 1 / 20
Total 202 questions