Question 1

Medicaid beneficiaries pose a challenge for health plans attempting to establish Medicaid provider networks. Compared to membership in commercial health plans, Medicaid enrollees typically

Options :

A : Require access to greater numbers of obstetricians and pediatricians

B : Have stronger relationships with primary care providers

C : Are less reliant on emergency rooms as a source of first-line care

D : Need fewer support and ancillary services

Answer: A

Question 2

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 :

A : is typically used for outpatient care

B : assigns a single code for treatment

C : applies to treatment received during an entire hospital stay

D : is considered to be a retrospective payment system

Answer: A

Question 3

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

Options :

A : Specialty IPA

B : Disease management company

C : Single specialty management specialist

D : Specialty network management company

Answer: B

Question 4

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. One important activity within the scope of network management is ensuring the quality of the health plan’s provider networks. A primary purpose of __ __ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan’s preestablished criteria for participation in the network.

Options :

A : authorization

B : provider relations

C : credentialing

D : utilization management

Answer: C

Question 5

The following statements are about fee-for-service (FFS) payment systems. Select the answer choice containing the correct statement:

Options :

A : A discounted fee-for-service (DFFS) system is usually easier for a health plan to administer than is a fee schedule system.

B : A case rate payment system offers providers an incentive to take an active role in managing cost and utilization.

C : One reason that health plans use a relative value scale (RVS) payment system is that RVS values for cognitive services have traditionally been higher than the values for procedural services.

D : One reason that health plans use a resource-based relative value scale (RBRVS) is that this system includes weighted unit values for all types of procedures.

Answer: B

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