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The Conquest Corporation contracts with the Apex health plan to provide basic medical and surgical services to Conquest employees. Conquest entered into a separate contract with the Bright Dental Group to provide and manage a dental care program for employee
The owners of an MCO typically delegate authority for governing the operation of the MCO by electing the MCO's
The following statements are about the make-up and function of an HMO's board of directors.
Select the answer choice that contains the correct statement.
The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms you have selected.
The Harbor Health Plan convened a litigation
The National Association of Insurance Commissioners' (NAIC's) Unfair Claims Settlement Practices Act specifies standards for the investigation and handling of claims. The Act defines unfair claims practices and notes that such practices are improper if the
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
Which of the following is NOT a reason for conducting utilization reviews?
One true statement about community rating, a rating method commonly used by health plans, is that:
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 ethical principle in managed care is the principle of justice/equity, which specifically holds that MCOs and their providers have a duty to
The Robust Health Plan sometimes uses prospective experience rating to calculate the premiums for a group. Under prospective experience rating, Robust most likely will:
Using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider is called ______________.
Wellborne HMO provides health-related information to its plan members through an Internet Web site. Laura Knight, a Wellborne plan member, visited Wellborne's Web site to gather uptodate information about the risks and benefits of various treatment option
Utilization review offers health plans a means of managing costs by managing
The act which requires each group health plan to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event that causes the loss of group health coverage is:
When determining the rates it will charge a small group, the Eagle HMO, a federally qualified HMO, divides its members into classes or groups based on demographic factors such as geography, family composition, and age. Eagle then charges all members of a
The Stateside Health Plan uses the following outcomes measures to evaluate the quality of its diabetes disease management program.
Measure A: Incidence of foot ulcers among long-term diabetes patients
Measure B: Ability of long-term diabetes patients to m
Which of the following statements about Family and Medical Leave Act (FMLA) is WRONG?
The National Association of Insurance Commissioners (NAIC) developed the Small Group Model Act to enable small groups to obtain accessible, yet affordable, group health benefits. The model law limits the rate spread, which is the difference between the highest and lowest rates that a health plan charges small groups, to a particular ratio.
According to the Model Act, for example, if the lowest rate an HMO charges a small group for a given set of medical benefits is $40, then the maximum rate the HMO can charge for the same set of benefits is
The following sentence contains an incomplete statement with two missing words. Select the answer choice that contains the words that correctly fill in the missing blanks.
At its core, consumer choice involves empowering healthcare consumers to play a __
The Advantage Health Plan recently added the following features to its member services program:
1. IVR
2. Active member outreach program
3. Advantage's member services staffing needs are likely to increase as a result of
Parable Healthcare Providers, a health plan, recently segmented the market for a new healthcare service. Parable began the process by dividing the healthcare market into two broad categories: non-group and group. Next, Parable further segmented the non-gr
Specialty services with certain characteristics tend to make good candidates for health plan approaches. One characteristic used to identify a specialty service that may be a good candidate for a health plan approach is that the service should have
The following organizations are the primary sources of accreditation of healthcare organizations:
Medicare Part C can be delivered by the following Medicare Advantage plans:
One of the most influential pieces of legislation in the advancement of health plans within the United States was the Health Maintenance Organization (HMO) Act of 1973. One of the provisions of the Act was that it
One way in which health plans differ from traditional indemnity plans is that health plans typically
One factor the Sandpiper Health Plan uses to assess its quality is a clinician's bedside manner, i.e., how friendly and understanding the clinician is, whether the patient feels that the clinician listens to the patient's concerns, how well the clinical
In large health plans, management functions such as provider recruiting, credentialing, contracting, provider service, and performance management for providers are typically the responsibility of the
In order to help review its institutional utilization rates, the Sahalee Medical Group, a health plan, uses the standard formula to calculate hospital bed days per 1,000 plan members for the month to date (MTD). On April 20, Sahalee used the following inf
A particular health plan offers a higher level of benefits for services provided in-network than for out-of-network services. This health plan requires preauthorization for certain medical services.
With regard to the steps that the health plan's claims e
Although the process is voluntary for health plans, external accreditation is becoming more and more important as states and purchasers require health plans undergo as many states and purchasers require health plans undergo some type of external review pr
Ed O'Brien has both Medicare Part A and Part B coverage. He also has coverage under a PBM plan that uses a closed formulary to manage the cost and use of pharmaceuticals. Recently, Mr. O'Brien was hospitalized for an aneurysm. Later, he was transferred by
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy
Because many patients with behavioral health disorders do not require round-the-clock nursing care and supervision, behavioral healthcare services can be delivered effectively in a variety of settings. For example, post-acute care for behavioral health di
A public employer, such as a municipality or county government would be considered which of the following?
In order to generate exchanges with consumers, healthcare plan marketers use the four elements of the marketing mix: product, price, place (distribution), and
An exclusive provider organization (EPO) operates much like a PPO. However, one difference between an EPO and a PPO is that an EPO
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
An HMO that combines characteristics of two or more HMO models is sometimes referred to as a
Federal Employee Health Benefits Program (FEHBP) requires health plans offering services to federal employees and their dependents to provide
Al Marak, a member of the Frazier Health Plan, has asked for a typical Level One appeal of a decision that Frazier made regarding Mr. Marak's coverage. One true statement about this Level One appeal is that
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
Dr. Julia Phram is a cardiologist under contract to Holcomb HMO, Inc., a typical closed-panel plan. The following statements are about this situation. Select the answer choice containing the correct statement.
In health plan terminology, demand management, as used by health plans, can best be described as
TESTED 28 Apr 2024