Question 1

In health plan pharmacy networks, service costs consist of two components: costs for services associated with dispensing prescription drugs and costs for cognitive services. Cognitive services typically include:

Options :

A : making generic substitutions of drugs

B : counseling patients about prescriptions

C : providing patient monitoring

D : switching prescription drugs to preferred drugs

Answer: B

Question 2

The provider contract that Dr. Laura Cartier has with the Sailboat health plan includes a section known as the recitals. Dr. Cartier's contract includes the following statements:

Options :

A : A statement that identifies the purpose of the contract

B : A statement that defines in legal terms the parties to the contract

C :

A statement that identifies the Sailboat products to be covered by the contract Of these statements, the ones that are likely to be included in the recitals section of Dr. Cartier's contract are statements:

D : A, B, and C

E : A and B only

F : A and C only

G : B and C only

Answer: A

Question 3

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 4

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 5

The following statements are about the negotiation process of provider contracting. Three of the statements are true and one of the statements is false. Select the answer choice containing the FALSE statement.

Options :

A :

While preparing for negotiations, the health plan usually sends the provider an application to join the provider network, a list of credentialing requirements, and a copy of the proposed provider contract, which may or may not include the proposed reimbursement schedule

B : In general, the ideal negotiating style for provider contracting is a collaborative approach.

C :

Typically, the health plan and the provider negotiate the reimbursement arrangement between the parties before they negotiate the scope of services and the contract language.

D :

The actual signing of the provider contract typically takes place after negotiations are completed.

Answer: C