Question 1

One reimbursement method that health plans can use for hospitals is the ambulatory payment classifications (APCs) method. APCs bear a resemblance to the diagnosis-related groups (DRGs) method of reimbursement. However, when comparing APCs and DRGs, one of the primary differences between the two methods is that only the APC method

Options :

A : is typically used for outpatient care

B : assigns a single code for treatment

C : applies to treatment received during an entire hospital stay

D : is considered to be a retrospective payment system

Answer: A

Question 2

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 3

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 4

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 5

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