NO.1 The following statement(s) can correctly be made about contracting and reimbursement of
specialty care physicians (SCPs):
A. Typically, a health plan should attempt to control utilization of SCPs before attempting to place
these providers under a capitation arrangement.
B. Forms of specialty physician reimbursement used by health plans include a retainer and a bundled
case rate.
C. Both A and B
D. A only
E. B only
F. Neither A nor B
Answer: A
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NO.2 Dr. Sarah Carmichael is one of several network providers who serve on one of the Apex Health
Plan's organizational committees. The committee reviews cases against providers identified through
complaints and grievances or through clinical monitoring activities. If needed, the committee
formulates, approves, and monitors corrective action plans for providers. Although Apex
administrators and other employees also serve on the committee, only participating providers have
voting rights. The committee that Dr. Carmichael serves on is a
A. Utilization management committee
B. Peer review committee
C. Medical advisory committee
D. Credentialing committee
Answer: B
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NO.3 In the paragraph below, two statements each contain a pair of terms enclosed in parentheses.
Determine which term correctly completes each statement. Then select the answer choice that
contains the two terms you have chosen.
In most states, a health plan can be held responsible for a provider's negligent malpractice. This legal
concept is known as (vicarious liability / risk sharing). One step that health plans can take to reduce
their exposure to malpractice lawsuits is to state in health plan-provider agreements,marketing
collateral, and membership literature that the providers are (employees of the health plan /
independent contractors).
A. Vicarious liability / employees of the health plan
B. Vicarious liability / independent contractors
C. Risk sharing / employees of the health plan
D. Risk sharing / independent contractors
Answer: B
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NO.4 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
Answer: C
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NO.5 One true statement about the compensation arrangement known as the case rate system is
that, under this system,
A. Providers stand to gain or lose based on the number and types of treatments used for each case
B. Providers have no incentives to take an active role in managing cost and utilization
C. Payors cannot adjust standard case rates to reflect the severity of the patient's condition or
complications that arise from multiple medical problems
D. Payors have the opportunity to benefit from the provider's cost savings
Answer: A
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NO.6 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
Answer: A
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NO.7 In 1996, the NAIC adopted a standard for health plan coverage of emergency services. This
standard is based on a concept known as the:
A. Due process standard
B. Subrogation standard
C. Corrective action standard
D. Prudent layperson standard
Answer: D
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NO.8 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
Answer: C
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