Question 1

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

Accepted Answer

The standard described is the prudent layperson standard, which was adopted by the NAIC in 1996. It defines 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.

Question 2

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.

Accepted Answer

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

Question 3

From the following answer choices, choose the type of clause or provision described in this situation. The Aviary Health Plan includes in its provider contracts a clause or provision that places the ultimate responsibility for an Aviary plan member's medical care on the provider.

Accepted Answer

The answer of From the following answer choices, choose the...

Question 4

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

Accepted Answer

Nonsolicitation clauses typically prevent providers from encouraging patients to switch from one health plan to another, as this could impact the business relationships and agreements between providers and health plans.

Question 5

The Brice Health Plan submitted to Clarity Health Services a letter of intent indicating Brice's desire to delegate its demand management function to Clarity. One true statement about this letter of intent is that it

Accepted Answer

A letter of intent typically includes a confidentiality clause to ensure that both parties maintain the confidentiality of any documents exchanged during the negotiation process.

Question 6

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

Accepted Answer

The best choice is D because it is true that a health plan must complete the credentialing process before a provider signs the network contract, or they must include a provision that the final contract is contingent upon the completion of the credentialing process. This is important to ensure that the provider is properly vetted and meets the qualifications and standards set by the health plan. A is false as health plans do not have the legal right to access a prospective provider's confidential medical records. B is false as the health plan may also assess qualitative factors such as quality of care and patient satisfaction during the credentialing process. C is false as by law health plans must verify a provider's scope of medical malpractice insurance coverage and federal tax identification number during the credentialing process.

Question 7

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:

Accepted Answer

The answer of The provider contract that Dr. Huang Kwan...

Question 8

In open panel contracting, there are several types of delivery systems. One such delivery system is the faculty practice plan (FPP). One likely result that a health plan will experience by contracting with an FPP is that the health plan will

Accepted Answer

By contracting with an FPP, a health plan may experience limited control over utilization because the FPP may have more autonomy in deciding which services and treatments to provide to patients. This can lead to challenges in managing costs and ensuring appropriate use of healthcare resources. The other options are not necessarily guaranteed outcomes of contracting with an FPP.

Question 9

Health plan contract negotiations with an integrated delivery system (IDS) or a hospital are usually lengthier and more complex than negotiations with a single-specialty provider.

Accepted Answer

Health plan contract negotiations with an integrated delivery system or hospital involve multiple departments and services, making the process lengthier and more complex than negotiations with a single-specialty provider. This is because the integrated delivery system or hospital may offer a range of services, and negotiations need to cover every service and department, including inpatient, outpatient, diagnostic, and laboratory services. The negotiations may involve multiple levels of management, including executives, medical directors, and financial officers, requiring more time and resources to reach an agreement.

Question 10

The NPDB specifies the entities that are eligible to request information from the data bank, as well as the conditions under which requests are allowed. In general, entities that are eligible to request information from the NPDB include

Accepted Answer

The entities that are eligible to request information from the NPDB include state licensing boards and professional societies that are screening applicants for membership. Medical malpractice insurers and the general public are not eligible entities.

Question 11

The following statements are about the responsibilities that providers are expected to assume under most provider contracts with health plans. Select the answer choice containing the correct statement.

Accepted Answer

Most health plans include clauses in provider contracts that require providers to maintain open communication with plan members about appropriate treatment plans, even if those services are not covered by the health plan.

Question 12

Determine whether the following statement is true or false: The NCQA has established a Physician Organization Certification (POC) program for the purpose of certifying medical groups and independent practice associations for delegation of certain NCQA standards, including data collection and verification for credentialing and recredentialing.

Accepted Answer

The statement is true. The National Committee for Quality Assurance (NCQA) has established a Physician Organization Certification (POC) program for certifying medical groups and independent practice associations for delegation of certain NCQA standards, including data collection and verification for credentialing and recredentialing.

Question 13

The following statement(s) can correctly be made about hospitalists. 1. The hospitalist's main function is to coordinate diagnostic and treatment activities to ensure that the patient receives appropriate care while in the hospital. 2. The hospitalist's role clearly supports the health plan concept of disease management.

Accepted Answer

The answer of The following statement(s) can correctly be made...

Question 14

The Justice Health Plan is eligible to submit reportable actions against medical practitioners to the National Practitioner Data Bank (NPDB). Justice is considering whether it should report the following actions to the NPDB: Action 1--A medical malpractice insurer made a malpractice payment on behalf of a dentist in Justice's network for a complaint that was settled out of court. Action 2--Justice reprimanded a PCP in its network for failing to follow the health plan's referral procedures. Action 3--Justice suspended a physician's clinical privileges throughout the Justice network because the physician's conduct adversely affected the welfare of a patient. Action 4--Justice censured a physician for advertising practices that were not aligned with Justice's marketing philosophy. Of these actions, the ones that Justice most likely must report to the NPDB include Actions

Accepted Answer

Action 1 involves a malpractice payment, which is a reportable offense by healthcare providers. Action 2 is a reprimand for not following referral procedures, which is not a reportable offense. Action 3 involves suspension of clinical privileges due to patient harm, which is reportable. Action 4 involves a censure for advertising practices, which is not a reportable offense. Therefore, Justice should report Actions 1 and 3 to the NPDB.

Question 15

From the following answer choices, choose the type of clause or provision described in this situation. The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.

Accepted Answer

An evergreen clause is a provision in a contract that allows for automatic renewal of the terms of the contract at the end of its term. In this situation, the Idlewilde Health Plan's provider contracts include an evergreen clause that allows the terms of the contract to renew unchanged each year.

Question 16

The provider contract between the Ocelot Health Plan and Dr. Enos Zorn, one of the health plan's participating providers, is a brief contract which includes, by reference, an Ocelot provider manual. This manual contains much of the information found in Ocelot's comprehensive provider contracts. The following statements are about Dr. Zorn's provider contract. Select the answer choice containing the correct statement.

Accepted Answer

Since the provider manual is incorporated by reference into the contract, Ocelot has an obligation to ensure that the manual is comprehensive and up-to-date. This means that the manual must contain all the information necessary for Dr. Zorn to fulfill his obligations under the contract. If Ocelot fails to meet this obligation, it could be in breach of the contract.

A is incorrect because not all statements in the contract are warranties. Only statements of fact that are material to the contract are considered to be warranties.

C is also incorrect because the fact that the contract is brief does not necessarily mean that Ocelot is prohibited from amending the contract unilaterally. The extent to which Ocelot can amend the contract will depend on the specific terms of the contract itself.

D is incorrect because the provider manual is not the appropriate place to address specific legal issues. Legal issues should be addressed in the contract itself.

Question 17

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

Accepted Answer

Health plans consider factors like patient delivery when deciding between capitated or fee-for-service reimbursement models.

Question 18

The introductory paragraph of a provider contract is generally followed by a section called the recitals. The recitals section of the contract typically specifies the

Accepted Answer

The recitals section of a provider contract typically outlines the purpose of the agreement, including the parties involved, the services to be provided, and any specific objectives or goals of the contract. It does not typically include information on billing, definitions of key terms, or compensation rates.

Question 19

Participating providers in a health plan's network must undergo recredentialing on a regular basis. During recredentialing, a health plan typically reviews

Accepted Answer

During recredentialing, a health plan typically reviews a provider's current, updated application information, as well as provider's peer reviews and performance reports on the provider. This helps the health plan ensure that the provider continues to meet the necessary standards for participation in the network. Option B, C, and D do not provide a complete picture of the recredentialing process.

Question 20

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. A credentials verification organization (CVO) can be certified to verify certain pertinent credentialing information, including

Accepted Answer

All three options listed (liability claims histories, hospital privileges, and malpractice insurance) can be verified by a certified credentials verification organization.

Exam 4: Network Management