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NEW QUESTION 1
Members who qualify to participate in a health plan's case management program are typically assigned a case manager. During the course of the member's treatment, the case manager is responsible for
- A. Coordinating and monitoring the member's care
- B. Approve
- C. Both A and B
- D. A only
- E. B only
- F. Neither A nor B
Answer: B
NEW QUESTION 2
The Gable MCO sometimes experience-rates small groups by underwriting a number of small groups as if they constituted one large group and then evaluating the experience of
the entire large group. This practice, which allows small groups to take advantage
- A. prospective experience rating
- B. pooling
- C. retrospective experience rating
- D. positioning
Answer: B
NEW QUESTION 3
One typical characteristic of preferred provider organization (PPO) benefit plans is that PPOs:
- A. Assume full financial risk for arranging medical services for their members.
- B. Require plan members to obtain a referral before getting medical services from specialists.
- C. Use a capitation arrangement, instead of a fee schedule, to reimburse physicians.
- D. Offer some coverage, although at a higher cost, for plan members who choose to use the services of non-network providers.
Answer: D
NEW QUESTION 4
The Polestar Company's sole business is the ownership of Polaris Medical Group, a health plan and subsidiary of Polestar. Some members of Polestar's board of directors hold positions with Polestar in addition to their positions on the board; the rest are professionals in academia and businesspeople who do not work for Polestar. Dr. Carolyn Porter, a university president, is on Polestar's board. From the following answer choices, select the response containing the term that correctly identifies Polestar's relationship to Polaris and the term that describes the type of board member represented by Dr. Porter
- A. Polestar's relationship to Polaris: partnership: Type of board member: operations director
- B. Polestar's relationship to Polaris: partnership: Type of board member: outside director
- C. Polestar's relationship to Polaris: holding company: Type of board member: operations director
- D. Poles tar's relationship to Polaris: holding company: Type of board member: outside director
Answer: D
NEW QUESTION 5
Janet Riva is covered by a traditional indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan.
- A. $1,750
- B. $1,800
- C. $2,000
- D. $2,250
Answer: B
NEW QUESTION 6
The parties to the contractual relationship that provides Castle's group health coverage to Knoll employees are
- A. Castle and Knoll only
- B. Knoll and all covered Knoll employees only
- C. Castle, Knoll, and all covered Knoll employees
- D. Castle and all covered Knoll employees only
Answer: A
NEW QUESTION 7
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. Advances in computer technology have revolutionized the processing of medical and drug claims. Claims processing i
- A. Lower
- B. Higher
- C. Same
- D. No change
Answer: B
NEW QUESTION 8
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy
- A. Health plans and their providers are obligated not to harm their members
- B. Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a group
- C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members
- D. Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives
Answer: D
NEW QUESTION 9
Ian Vladmir wants to have a routine physical examination to ascertain that he is in good health. Mr. Vladmir is a member of a health plan that will allow him to select the physician of his choice, either from within his plan's network or from outside of h
- A. a traditional HMO plan
- B. a managed indemnity plan
- C. a point of service (POS) option
- D. an exclusive provider organization (EPO)
Answer: C
NEW QUESTION 10
Which of the following is WRONG?
- A. Computer Based Patient Records Institute (CPRI) developed the standards for digital imaging of xrays.
- B. HL7 developers focuses on interchange of Clinical Health Data
- C. ANSI, a voluntary national standards organization, creates a consensus based process by which fair and equitable standards can be developed and serves as a legitmizer of standards.
- D. American Health Information Management Association focuses on EDI standards for exchange of clinical data
Answer: A
NEW QUESTION 11
A medical foundation is a not-for-profit entity that purchases and manages physician practices. In order to retain its not-for-profit status, a medical foundation must
- A. Provide significant benefit to the community
- B. Employ, rather than contract with, participating physicians
- C. Achieve economies of scale through facility consolidation and practice management
- D. Refrain from the corporate practice of medicine
Answer: A
NEW QUESTION 12
Which of the following is an example of physician only model of operational integration?
- A. Consolidated medical group
- B. Integrated Delivery System
- C. Medical Foundation
- D. Both B & C
Answer: A
NEW QUESTION 13
The Robust Health Plan sometimes uses prospective experience rating to calculate the premiums for a group. Under prospective experience rating, Robust most likely will:
- A. At the end of a rating period, the financial gains and losses experienced by the group during that rating period and, if the group's experience during the period is better than expected, refund part of the group's premium in the form of an experience ratio
- B. Use Robust's average experience with all groups to calculate this particular group's premium.
- C. Use the group's past experience to estimate the group's expected experience for the next period.
- D. All of the above
Answer: C
NEW QUESTION 14
Which of the following best describes an organization that is owned by a hospital or group of investors and provides management and administrative support services to individual physicians or small group practices?
- A. Independent Practice Association (IPA).
- B. Group Practice Without Walls (GPWW)
- C. Management Services Organization (MSO).
- D. Consolidated Medical Group.
Answer: C
NEW QUESTION 15
Many HMOs are compensated for the delivery of healthcare to members under a prepaid care arrangement. Under a prepaid care arrangement, a plan member typically pays a
- A. fixed amount in advance for each medical service the member receives
- B. a small fee such as $10 or $15 that a member pays at the time of an office visit to a network provider
- C. a fixed, monthly premium paid in advance of the delivery of medical care that covers most healthcare services that a member might need, no matter how often the member uses medical services
- D. specified amount of the member's medical expenses before any benefits are paid by the HMO
Answer: C
NEW QUESTION 16
What is a mathematical process that involves using a number of hypothetical situations that, in total, will reasonably reflect an event that will occur in real life
- A. Forecasting
- B. Modelling
- C. Both a and b
- D. None of the above
Answer: B
NEW QUESTION 17
Which of the following features differentiates a 'Clinic without walls1 from a consolidated medical group?
- A. Unlike a consolidated medical group, physicians in a 'Clinic without walls' maintain their practices independently in multiple locations.
- B. Unlike a consolidated medical group, a 'Clinic without walls' performs or arranges for business operations for the member physicians.
- C. Both A & B
Answer: A
NEW QUESTION 18
The Panacea Healthcare System is a single large medical practice based in Oakland, California. The physicians of Panacea operate through a single office located in the Beverly Hills region of Oakland & do have access to the same medical records. Panacea is owned by Queen's hospital & before Panacea acquired the practices of its participating physicians, these physicians were independent practitioners. Which of the following terms best describes Panacea?
- A. Physician Practice Management Compare
- B. Physician Hospital Organization
- C. Consolidated Medical Group
- D. None of the above
Answer: C
NEW QUESTION 19
The process that Mr. Sybex used to identify and classify the risk represented by the Koster Group so that Intuitive can charge premiums that are adequate to cover its expected costs is known as
- A. coinsurance
- B. plan funding
- C. underwriting
- D. pooling
Answer: C
NEW QUESTION 20
The administrative simplification standards described under Title II of HIPAA include
privacy standards to control the use and disclosure of health information. In general, these privacy standards prohibit
- A. all health plans, healthcare providers, and healthcare clearinghouses from using any protected health information for purposes of treatment, payment, or healthcare operations without an individual's written consent
- B. patients from requesting that restrictions be placed on the accessibility and use of protected health information
- C. transmission of individually identifiable health information for purposes other than treatment, payment, or healthcare operations without the individual's written authorization
- D. patients from accessing their medical records and requesting the amendment of incorrect or incomplete information
Answer: D
NEW QUESTION 21
The feature that formed the foundation of Health Maintenance Act of 1973
- A. Federal Qualification Requirements
- B. Exemption from state laws
- C. All of the above
Answer: C
NEW QUESTION 22
One HMO model can be described as an extension of a group model HMO because it contracts with multiple group practices, rather than with a single group practice. This HMO model is known as the
- A. staff model HMO
- B. IPA model HMO
- C. direct contract model HMO
- D. network model HMO
Answer: D
NEW QUESTION 23
Immediate evaluation and treatment of illness or injury can be provided in any of the following care settings:
- A. Hospital emergency departments
- B. Physician's offices
- C. Urgent care centersIf these settings are ranked in order of the cost of providing c
- D. A, B, C
- E. A, C, B
- F. B, C, A
- G. C, A, B
Answer: B
NEW QUESTION 24
Bill Clinton is a member of Lewinsky's PBM plan which has a three-tier copayment structure. Bill fell ill and his doctor prescribed him AAA, a brand-name drug which was included in the Lewinsky's formulary; BBB, a non-formulary drug; and CCC, a generic dr
- A. CCC, AAA, BBB
- B. BBB, CCC, AAA
- C. BBB, AAA, CCC
- D. CCC, BBB, AAA
Answer: A
NEW QUESTION 25
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. In early efforts to manage healthcare costs, traditional indemnity health insurers included in their health pla
- A. cost shifting
- B. deductibles
- C. underwriting
- D. copy
Answer: B
NEW QUESTION 26
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