The Titanium Health Plan and a third-party administrator (TPA) have entered into a TPA agreement with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. One of the TPA's
The following statements apply to flexible spending arrangements. Select the answer choice that contains the correct statement.
The health plan determines what it considers to be the acceptable fee for a service or procedure and the physician agrees to accept that amount as payment in full for the procedure
Using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider is called ______________.
The following statements describe individuals who are applying for individual health insurance coverage:
Six months ago, Wilbur Lee lost his health insurance coverage due to a reduction in work hours and has exhausted his coverage under COBRA. Mr. Lee has
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy
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
Beginning in the early 1980s, several factors contributed to increased demand for behavioral healthcare services. These factors included
An HMO that combines characteristics of two or more HMO models is sometimes referred to as a
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
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
If most of the physicians, or many of the physicians in a particular specialty, are affiliated with a single entity, then a health plan building a network in the service area _____________.
HMOs typically employ several techniques to manage provider utilization and member utilization of medical services. One technique that an HMO uses to manage member utilization is
All CDHP products provide federal tax advantages while allowing consumers to save money for their healthcare.
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
From the following choices, choose the definition that best matches the term Screening
From the answer choices below, select the response that correctly identifies the rating method that Mr. Sybex used and the premium rate PMPM that Mr. Sybex calculated for the Koster group.
In response to the demand for a method of assessing outcomes, accrediting organizations and other government and commercial groups have developed quantitative measures of quality that consumers, purchasers, regulators, and others can use to compare health
In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known
Utilization data can be transmitted to the health plan manually, by telephone, or electronically. Compared to other methods of data transmittal, manual transmittal is generally
Combined system of preventive, diagnostic and therapeutic measures that focuses on management of specific chronic illness or medical conditions are:
The Madison Health Plan, a national MCO, and a local hospital system that operates its own managed healthcare network recently created a new and separate managed healthcare organization, the Pineapple Health Plan. Madison and the hospital system share own
PBM plans operate under several types of contractual arrangements. Under one contractual arrangement, the PBM plan and the employer agree on a target cost per employee per month. If the actual cost per employee per month is greater than the target cost, t
The data evaluation stage of utilization review (UR) includes both administrative reviews and medical reviews. One true statement about these types of reviews is that:
Janet Riva is covered by a 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. She incurred
One type of physician-only integration model is a consolidated medical group. Typical characteristics of a consolidated medical group include
Specialty services with certain characteristics tend to make good candidates for health plan approaches. One characteristic used to identify a specialty service that may be a good candidate for a health plan approach is that the service should have
The application of health plan principles to workers' compensation insurance programs has presented some unique challenges because of the differences between health plan for traditional group healthcare and workers' compensation. One key difference is that
Lansdale Healthcare, a health plan, offers comprehensive healthcare coverage to its members through a network of physicians, hospitals, and other service providers. Plan members who use in-network services pay a copayment for these services. The copayment
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
Some providers use electronic medical records (EMRs) to document their patients' care in an electronic form. The following statement(s) can correctly be made about EMRs:
Primary care case managers (PCCMs) provide managed healthcare services to eligible Medicaid recipients. With regard to PCCMs, it is correct to say that
The following programs are part of the Alcove MCO's utilization management (UM) program:
With regard to the UM programs, it is most likely cor
One way in which health plans differ from traditional indemnity plans is that health plans typically
One distinguishing characteristic of a health maintenance organization (HMO) is that, typically, an HMO
The Clover Group is a for-profit MCO that operates in the United States. The Valentine Group owns all of Clover's stock. The Valentine Group's sole business is the ownership of controlling interests in the shares of other companies. This information indic
One of the most influential pieces of legislation in the advancement of managed care within the United States was the HMO Act of 1973. One provision of the HMO Act of 1973 was that it
Katrina Lopez is a claims analyst for a health plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Ms. Lopez reviewed a health claim for answers to the following questions:
Question A -
The Venus Hospital provides medical care to paying patients, as well as to people who either have no healthcare coverage and cannot pay for the care by themselves or who receive services at reduced rates because they are covered under government sponsored
To address the problems associated with multiple data management systems, the Kayak Health Plan has begun to use a data warehouse. One likely characteristic of Kayak's data warehouse is that:
After a somewhat modest start in 2004, enrollment in HSA-related health plans more than tripled in 2005, making them today’s fastest growing type of CDHP. As of January 2006, enrollment in HSAs had reached nearly:
The main purpose of the Health Plan Employer Data and Information Set (HEDIS) is to provide
The Helm MCO segmented the non-group market for its new healthcare product by using factors such as education level, gender, and household composition. The Amberly MCO segmented the non-group market for its products based on the approaches by which it sol
The situation wherein two hospitals agree to each refuse to contract with a health plan until the health plan cease contract negotiations with a competing hospital is known as
The Mosaic health plan uses a typical electronic medical record (EMR) to document the medical care its members receive. One characteristic of Mosaic's EMR is that it:
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TESTED 13 May 2024
