Question 1

The Walnut Health Plan provides a number of specialty services for its members. Walnut offers coverage of alternative healthcare, including coverage of treatment methods such as homeopathy and naturopathy. Walnut also offers home healthcare services, and it contracts with home healthcare providers on a non-risk basis to the health plan. The following statements are about the specialty services offered by Walnut. Select the answer choice containing the correct statement:

Options :

A :

Homeopathy treats diseases by using small doses of substances which, in healthy people, are capable of producing symptoms like those of the disease being treated.

B :

Naturopathy is an approach to healthcare that uses electronic monitoring devices to teach a patient to develop conscious control of involuntary bodily functions, such as heart rate.

C :

Under a non-risk contract, Walnut most likely transfers the responsibility for arranging home healthcare to the home healthcare provider organizations.

D :

Federal law allows Walnut to contract with a home healthcare provider organization only if the provider organization has received accreditation by the Utilization Review Accreditation Commission (URAC).

Answer: A

Question 2

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.

The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan

member for covered services is known as:

Options :

A : Atermination with cause clause

B : Ahold-harmless clause

C : An indemnification clause

D : Acorrective action clause

Answer: B

Question 3

The following statements are about the negotiation process of provider contracting. Three of the statements are true and one of the statements is false. Select the answer choice containing the FALSE statement.

Options :

A : While preparing for negotiations, the health plan usually sends the provider an application to join the provider network, a list of credentialing requirements, and a copy of the proposed provider contract, which may or may not include the proposed reimbursement schedule

B : In general, the ideal negotiating style for provider contracting is a collaborative approach.

C : Typically, the health plan and the provider negotiate the reimbursement arrangement between the parties before they negotiate the scope of services and the contract language.

D : The actual signing of the provider contract typically takes place after negotiations are completed.

Answer: C

Question 4

The following statements are about workers' compensation provider networks. Select the answer choice containing the correct statement:

Options :

A : In order to supply a provider network to furnish healthcare to workers' compensation beneficiaries, a health plan typically uses the network that has already been created for the group health plan.

B : Typically, case managers for workers' compensation programs are physical therapists.

C : Most states prohibit the use of fee schedules in order to curb the rising workers' compensation healthcare costs.

D : Networks serving workers' compensation patients typically include higher concentrations of specialists than do other provider networks.

Answer: D

Question 5

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

Answer: B

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