Question 1

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 2

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. One important activity within the scope of network management is ensuring the quality of the health plan’s provider networks. A primary purpose of __ __ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan’s preestablished criteria for participation in the network.

Options :

A : authorization

B : provider relations

C : credentialing

D : utilization management

Answer: C

Question 3

A population’s demographic factors—such as income levels, age, gender, race, and ethnicity—can influence the design of provider networks serving that population. With respect to these demographic factors, it is correct to say that

Options :

A :

higher-income populations have a higher incidence of chronic illnesses than do lowerincome populations

B : compared to other groups, young men are more likely to be attached to particular providers

C :

a population with a high proportion of women typically requires more providers than does a population that is predominantly male

D :

Health plans should not recognize, in either the design of networks or the evaluation of provider performance, racial and ethnic differences in the member population

Answer: C

Question 4

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 5

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she

cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon

becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon

will compensate her under a typical discounted fee-for-service (DFFS) payment system.

During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan

determine how well she met Canyon's standards. The report included cumulative performance

data for Dr. Enberg and encompassed all measurable aspects of her performance. This report

included such information as the number of hospital admissions Dr. Enberg had and the number of

referrals she made outside of Canyon's provider network during a specified period. Canyon also

used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's

performance.

The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan

member for covered services is known as:

Options :

A : Atermination with cause clause

B : Ahold-harmless clause

C : An indemnification clause

D : Acorrective action clause

Answer: B

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