Question 1

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

Question 2

With respect to hiring practices, one step that a health plan most likely can take to avoid violating the terms of the Americans with Disabilities Act (ADA) is to

Options :

A : Require a medical examination prior to accepting an application for employment

B : Include in the employment application questions pertaining to health status

C :

Make a conditional offer of employment, and then require the candidate to have an examination prior to granting specific staff privileges

D : Require applicants to answer questions pertaining to the use of drugs and alcohol

Answer: C

Question 3

The following statements are about fee-for-service (FFS) payment systems. Select the answer choice containing the correct statement:

Options :

A :

A discounted fee-for-service (DFFS) system is usually easier for a health plan to administer than is a fee schedule system.

B :

A case rate payment system offers providers an incentive to take an active role in managing cost and utilization.

C :

One reason that health plans use a relative value scale (RVS) payment system is that RVS values for cognitive services have traditionally been higher than the values for procedural services.

D :

One reason that health plans use a resource-based relative value scale (RBRVS) is that this system includes weighted unit values for all types of procedures.

Answer: B

Question 4

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 5

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