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Keith Murray is a 45 year old chartered accountant & is employed in Livingstone consultancy firm. He has been paying payroll taxes for the past 15 years. Which of the following statements is true regarding Medicare Part A entitlement?
The following statements are about the non-group market for managed care products in the United States. Select the answer choice containing the correct statement.
Dr. Julia Phram is a cardiologist under contract to Holcomb HMO, Inc., a typical closed-panel plan. The following statements are about this situation. Select the answer choice containing the correct statement.
If a state commissioner of insurance places an HMO under administrative supervision, then the purpose of this action most likely is to:
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence
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 _____________.
In order to measure the expenses of institutional utilization, Holt Health care group uses standard formula to calculate hospital bed stays per 1000 plan members. On 26 November, Holt uses the following information to:
Calculate the bed days per 1000 members for the MTD
Total gross hospital bed days in MTD = 500
Plan membership = 15000
Calculate Holt's number of bed days per 1000 members for the month to date, rounded to the nearest whole number.
The Military Health System of the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the
Khalyn Drury's employer includes managed dental care in its employee benefits package. During open enrollment, Ms. Drury enrolled in the dental plan, which provides dental services to its members in exchange for a prepayment (the premium). Dental services
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
Consolidation of patient information in a single location as can be used by independent providers is an example of
The Internal Revenue Service has ruled that an HDHP coupled with an HSA may cover certain types of preventive care without a deductible or with a lower amount than the annual deductible applicable to all other services. According to IRS guidance, which on
The following statements are about federal laws that affect healthcare organizations. Select the answer choice containing the correct response.
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 Koster Company plans to purchase a health plan for its employees from Intuitive HMO. Intuitive will administer the plan and will bear the responsibility of guaranteeing claim payments by paying all incurred covered benefits. Koster will pay for the he
The following statements pertain to the federal requirements for minimum deductible & maximum out of pocket expeses for a high deductible health plan in the year 2006. Select the correct answer from the options given below.
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
The following statements describe violations of antitrust legislation:
Situation A - Two health plans in a single service area divided purchasers into two groups and agreed to each market their products to only one purchaser group.
Situation B - A spec
The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential
The following statements are about standards set forth in the Quality Improvement System for Managed Care (QISMC), established by the Health Care Financing Administration (HCFA, now known as the Centers for Medicare and Medicaid Services).
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence
Federal Employee Health Benefits Program (FEHBP) requires health plans offering services to federal employees and their dependents to provide
Two MCOs in a single service area divided purchasers into two groups and agreed to each market their products to only one purchaser group. This information indicates that these two MCOs violated antitrust requirements because they engaged in an activity k
In order to generate exchanges with consumers, healthcare plan marketers use the four elements of the marketing mix: product, price, place (distribution), and
Health plans use the following to determine the number of providers to add to a network:
According to the IRS, which of the following is not an allowable preventive care service?
A health plan's ability to establish an effective provider network depends on the characteristics of the proposed service area and the needs of proposed plan members. It is generally correct to say that
Health plans' use of the Internet to provide plan members with health-related information has grown rapidly in recent years. One advantage the Internet has over other forms of communication is that
All CDHP products provide federal tax advantages while allowing consumers to save money for their healthcare.
Bart Vereen is insured by both a traditional indemnity health insurance plan, which is his primary plan, and a managed care plan. Both plans have a typical coordination of benefits (COB) provision, but neither plan has a nonduplication of benefits provision
Before the Leo Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the
Before an HMO contracts with a physician, the HMO first verifies the physician's credentials.
Upon becoming part of the HMO's organized system of healthcare, the physician is typically subject to
Dr. Milton Ware, a physician in the Riverside MCO's network of providers, is reimbursed under a fee schedule arrangement for medical services he provides to Riverside members. Dr. Ware's provider contract with Riverside contains a typical no-balance billi
In the paragraph below, a sentence contains two pairs of words enclosed in parentheses. Determine which word in each pair correctly completes the sentence. Then select the answer choice containing the two words that you have chosen. Many pharmacy benefit
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
As part of its quality management program, the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. When Lyric concludes that its competitor's practices or services are better than its own, Lyric im
Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called:
Al Marak, a member of the Frazier Health Plan, has asked for a typical Level One appeal of a decision that Frazier made regarding Mr. Marak's coverage. One true statement about this Level One appeal is that
In 1999, the United States Congress passed the Financial Services Modernization Act, which is referred to as the Gramm-Leach-Bliley (GLB) Act. The following statement(s) can correctly be made about this act:
Greentree Medical, a health plan, is currently recruiting PCPs in preparation for its expansion into a new service area. Abigail Davis, a recruiter for Greentree, has been meeting with Melissa Cortelyou, M.D., in an effort to recruit her as a PCP in Green
Col. Martin Avery, on active duty in the U.S. Army, is eligible to receive healthcare benefits under one of the three TRICARE health plan options. If Col Avery elects to participate in TRICARE Prime, he will be
Identify the CORRECT statement(s):
(A) Smaller the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.
(B) Gender of the group's participants has no effect on the likelihood of loss.
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
Immediate evaluation and treatment of illness or injury can be provided in any of the following care settings:
A physician-hospital organization (PHO) may be classified as an open PHO or a closed PHO. With respect to a closed PHO, it is correct to say that
A health savings account must be coupled with an HDHP that meets federal requirements for minimum deductible and maximum out-of-pocket expenses. Dollar amounts are indexed annually for inflation. For 2006, the annual deductible for self-only coverage must
As part of its utilization management (UM) system, the Creole Health Plan uses a process known as case management. The following individuals are members of the Creole Health Plan:
Following a report by the Institute of Medicine on the incidence and consequences of medical errors, a national task force recommended implementation of a nationwide mandatory system of collecting, analyzing, and reporting standardized information about m
A public employer, such as a municipality or county government would be considered which of the following?
The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential
The National Association of Insurance Commissioners (NAIC) developed the Small Group Model Act to enable small groups to obtain accessible, yet affordable, group health benefits. The model law limits the rate spread, which is the difference between the hi
Salient features of a Health Savings Account include all of the following except
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
The following statements are about health information networks (HINs). Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement.
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?
The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential
The main advantage of using outcomes measures to evaluate healthcare quality is that they Typically
The parties to the contractual relationship that provides Castle's group health coverage to Knoll employees are
The following statements are about concepts related to the underwriting function within a health plan. Select the answer choice containing the correct statement.
The following statements are about issues associated with marketing healthcare plans to small groups and large groups. Select the answer choice that contains the correct statement.
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 ______________.
Which of the following factors have contributed to the limited popularity of FSAs
The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.
One device that PBM plans use to manage both the cost and use of pharmaceuticals is a formulary. A formulary is defined as
The following sentence contains an incomplete statement with two missing words. Select the answer choice that contains the words that correctly fill in the missing blanks.
At its core, consumer choice involves empowering healthcare consumers to play a __
The following statement can be correctly made about Medicare Advantage eligibility:
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
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
John Kerry's employer has contracted to receive healthcare for its employees from the Democratic Healthcare System. Mr. Kerry visits his PCP, who sends him to have some blood tests. The PCP then refers Mr. Kerry to a specialist who hospitalizes him for on
Several marketplace factors helped fuel the movement toward consumer choice. Which one of the following statements is NOT accurate with regard to these factors?
Phillip Tsai is insured by both a indemnity health insurance plan, which is his primary plan, and a health plan, which is his secondary plan. Both plans have typical coordination of benefits (COB) provisions, but neither has a nonduplication of benefits p
The Employee Retirement Income Security Act (ERISA) requires health plan members who receive healthcare benefits through employee benefit plans to file legal challenges involving coverage decisions or plan administration at the federal level. Under the te
One distinguishing characteristic of a health maintenance organization (HMO) is that, typically, an HMO
The following organizations are the primary sources of accreditation of healthcare organizations:
The Acme HMO recruits and contracts directly with a wide range of physicians—both PCPs and specialists—in its geographic area on a non-exclusive basis. There is no separate legal entity that represents and negotiates the contracts for the physicians. The
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
Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involves
Natalie Chan is a member of the Ultra Health Plan, a health plan. Whenever she needs nonemergency medical care, she sees Dr. David Craig, an internist. Ms. Chan cannot self-refer to a specialist, so she saw Dr. Craig when she experienced headaches. Dr. Cr
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
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
In the United States, the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the TRICARE health plan. One true statement about TRICARE is that:
The following sentence contains an incomplete statement with two missing words. Select the answer choice that contains the words that correctly fill the two blanks, respectively. The philosophy of consumer choice involves having consumers play a(n) ______
The Cleopatra Group, a third-party administrator (TPA), has entered into a TPA agreement with the Alexander MCO with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. On
Merle Spencer has coverage under both Medicare Part A and Medicare Part B. Ms. Spencer recently was hospitalized for chest pains, and she incurred charges for:
Medicaid is a jointly funded federal and state program that provides hospital and medical expense coverage to low-income individuals and certain aged and disabled individuals. One characteristic of Medicaid is that
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:
The Conquest Corporation contracts with the Apex health plan to provide basic medical and surgical services to Conquest employees. Conquest entered into a separate contract with the Bright Dental Group to provide and manage a dental care program for employee
Managed behavioral health organizations (MBHOs) use several strategies to manage the delivery of behavioral healthcare services. The following statements are about these strategies.
Select the answer choice that contains the correct statement.
The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.
TESTED 23 Nov 2024