Question 1

Medicaid beneficiaries pose a challenge for health plans attempting to establish Medicaid provider networks. Compared to membership in commercial health plans, Medicaid enrollees typically

Options :

A : Require access to greater numbers of obstetricians and pediatricians

B : Have stronger relationships with primary care providers

C : Are less reliant on emergency rooms as a source of first-line care

D : Need fewer support and ancillary services

Answer: A

Question 2

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 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

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 5

With respect to contractual provisions related to provider-patient communications, nonsolicitation clauses prohibit providers from

Options :

A : Encouraging patients to switch from one health plan to another

B : Disclosing confidential information about the health plan’s reimbursement structure

C : Dispersing confidential financial information regarding the health plan

D : Discussing alternative treatment plans with patients

Answer: A