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AHIP AHM-530 - Network Management

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Total 202 questions

Factors that are likely to indicate increased health plan market maturity include:

A.

Increased consolidation among health plans.

B.

Increased rate of growth in health plan premium levels.

C.

Areduction in the market penetration of HMO and point-of-service (POS) products.

D.

Areduction in the frequency of performance-based reimbursement of providers.

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

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.

The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:

A.

Must provide Medicare participants with standard HMO benefits, as well as with limited long-term care benefits

B.

Does not need as great a variety of provider types or as complex a reimbursement method as does a traditional HMO

C.

Receives a payment that is based on reasonable costs and reasonable charges

D.

Most likely provides fewer supportive services than does a traditional HMO, because one of Bruin's goals is to minimize the use of community-based care

In order to evaluate and manage the performance of individual providers in its provider network, the Quorum Health Plan implemented a program that focuses on identifying the best and worst outcomes and utilization patterns of its providers. This program is also designed to develop and implement strategies such as treatment protocols and practice guidelines to improve the performance of Quorum's providers. This information indicates that Quorum implemented a program known as:

A.

An integrated delivery system (IDS)

B.

A coordinated care program

C.

Ostensible agency

D.

Continuous quality improvement (CQI)

The following statement(s) can correctly be made about the Balanced Budget Act (BBA) of 1997:

A.

The BBA requires Medicare+Choice organizations to be licensed as non-risk-bearing entities under federal law.

B.

The Centers for Medicaid and Medicare Services (CMS) is responsible for implementing the BBA.

C.

Both A and B

D.

A only

E.

B only

F.

Neither A nor B

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 report that helped Canyon determine how well Dr. Enberg met the health plan's standards is known as:

A.

An encounter report

B.

An external standards report

C.

Aprovider profile

D.

An access to care report

With regard to the compensation of dental care providers in a managed dental care system, it is correct to state that, typically:

A.

dental PPOs compensate dentists on a capitated basis

B.

group model dental HMOs (DHMOs) compensate general dental practitioners on a salaried basis

C.

independent practice association (IPA)-model dental HMOs (DHMOs) capitate general dental practitioners

D.

staff model dental HMOs (DHMOs) compensate dentists on an FFS basis

If a member of the Green Health Plan reasonably believes that a provider in Green's provider network was acting as Green's employee or agent while providing negligent care, then the member may have cause to bring action against the health plan. This legal concept is known as vicarious liability. Steps that Green can take to reduce its exposure to vicarious liability claims include:

A.

Placing restrictions on provider-member communication involving treatment decisions.

B.

Implementing risk management and quality assurance programs for its provider network.

C.

Including in its provider agreements and marketing and membership literature a statement that members of the Green provider network are not independent contractors.

D.

All of the above.

The Adobe Health Plan complies with all of the provisions of the Newborns' and Mothers' Health Protection Act (NMHPA) of 1996. Kristen Netzger, an Adobe enrollee, was hospitalized for a cesarean delivery. Amy Davis, also an Adobe enrollee, was hospitalized for a normal delivery. From the following answer choices, select the response that indicates the minimum length of time for which Adobe, under NMHPA, most likely must provide benefits for the hospitalizations of Ms. Netzger and Ms. Davis.

A.

Ms. Netzger = 48 hours

Ms. Davis = 48 hours

B.

Ms. Netzger = 72 hours

Ms. Davis = 72 hours

C.

Ms. Netzger = 96 hours

Ms. Davis = 48 hours

D.

Ms. Netzger = 96 hours

Ms. Davis = 72 hours

The following activities are the responsibility of either the Nova Health Plan's risk management department or its medical management department:

A.

Protecting Nova's members against harm from medical care

B.

Improving the overall health status of Nova members by coordinating care across individual episodes of care and the different providers who treat the member

C.

Protecting Nova against financial loss associated with the delivery of healthcare

D.

Establishing outreach programs to encourage the use of preventive health services by Nova's members of these activities, the ones that are more likely to be the responsibility of Nova's risk management department rather than its medical management department are activities:

E.

A, B, and C

F.

A, C, and D

G.

A and C