Question 1

Dr. Eve Barlow is a specialist in the Amity Health Plan’s provider network. Dr. Barlow’s provider contract with Amity contains a typical most-favored-nation arrangement. The purpose of this arrangement is to

Options :

A : Require Dr. Barlow and Amity to use arbitration to resolve any disputes regarding the contract

B :

Specify that the contract is to be governed by the laws of the state in which Amity has its headquarters

C :

Require Dr. Barlow to charge Amity her lowest rate for a medical service she has provided to an Amity plan member, even if the rate is lower than the price negotiated in the contract

D :

State that the contract creates an employment or agency relationship, rather than an independent contractor relationship, between Dr. Barlow and Amity

Answer: C

Question 2

The Walnut Health Plan provides a number of specialty services for its members. Walnut offers coverage of alternative healthcare, including coverage of treatment methods such as homeopathy and naturopathy. Walnut also offers home healthcare services, and it contracts with home healthcare providers on a non-risk basis to the health plan. The following statements are about the specialty services offered by Walnut. Select the answer choice containing the correct statement:

Options :

A :

Homeopathy treats diseases by using small doses of substances which, in healthy people, are capable of producing symptoms like those of the disease being treated.

B :

Naturopathy is an approach to healthcare that uses electronic monitoring devices to teach a patient to develop conscious control of involuntary bodily functions, such as heart rate.

C :

Under a non-risk contract, Walnut most likely transfers the responsibility for arranging home healthcare to the home healthcare provider organizations.

D :

Federal law allows Walnut to contract with a home healthcare provider organization only if the provider organization has received accreditation by the Utilization Review Accreditation Commission (URAC).

Answer: A

Question 3

One reimbursement method that health plans can use for hospitals is the ambulatory payment classifications (APCs) method. APCs bear a resemblance to the diagnosis-related groups (DRGs) method of reimbursement. However, when comparing APCs and DRGs, one of the primary differences between the two methods is that only the APC method

Options :

A : is typically used for outpatient care

B : assigns a single code for treatment

C : applies to treatment received during an entire hospital stay

D : is considered to be a retrospective payment system

Answer: A

Question 4

The Ionic Group, a provider group with 10,000 plan members, purchased for its hospital risk pool aggregate stop-loss insurance with a threshold of 110% of projected costs and a 10% coinsurance provision. Ionic funds the hospital risk pool at $40 per member per month (PMPM). If Ionic’s actual hospital costs are $5,580,000 for the year, then, under the aggregate stop-loss agreement, the stop-loss insurer is responsible for reimbursing Ionic in the amount of

Options :

A : $30,000

B : $270,000

C : $300,000

D : $702,000

Answer: B

Question 5

The provider contract that Dr. Nick Mancini has with the Utopia Health Plan includes a clause that requires Utopia to reimburse Dr. Mancini on a fee-for-service (FFS) basis until 100 Utopia members have selected him as their primary care provider (PCP). At that time, Utopia will begin reimbursing him under a capitated arrangement. This clause in Dr. Mancini's provider contract is known as:

Options :

A : an antidisparagement clause

B : a low-enrollment guarantee clause

C : a retroactive enrollment changes clause

D : an eligibility guarantee clause

Answer: B

Confidently Practice Online with Free AHM-530 Exam Cram

Buying Options: