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One distinguishing characteristic of a health maintenance organization (HMO) is that, typically, an HMO
The participating physicians remain independent practitioners who operate out of their own offices and can treat other patients in addition to Kayak plan members. Kayak can correctly be characterized as
Health plans can organize under a not-for-profit form or a for-profit form. One true statement regarding not-for-profit health plans is that these organizations typically
The Madison Health Plan, a national MCO, and a local hospital system that operates its own managed healthcare network recently created a new and separate managed healthcare organization, the Pineapple Health Plan. Madison and the hospital system share own
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
The process of identifying and classifying the risk represented by an individual or group is called
In order to help review its institutional utilization rates, the Sahalee Medical Group, a health plan, uses the standard formula to calculate hospital bed days per 1,000 plan members for the month to date (MTD). On April 20, Sahalee used the following inf
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
Exclusive provider organizations (EPO) is similar and operates like a PPO in administration, structure but however in an EPO an out-of-network care is
The Panacea Healthcare System is a single large medical practice based in Oakland, California. The physicians of Panacea operate through a single office located in the Beverly Hills region of Oakland & do have access to the same medical records. Panacea is owned by Queen's hospital & before Panacea acquired the practices of its participating physicians, these physicians were independent practitioners. Which of the following terms best describes Panacea?
The nature of the claims function within health plans varies by type of plan and by the compensation arrangement that the plan has made with its providers. For example, it is generally correct to say that, in a
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
In health plan terminology, demand management, as used by health plans, can best be described as
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.
By offering a comprehensive set of healthcare benefits to its members, an HMO ensures that its members obtain quality, cost-effective, and appropriate medical care. Ways that an HMO provides comprehensive care include
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
Bill Clinton is a member of Lewinsky's PBM plan which has a three-tier copayment structure. Bill fell ill and his doctor prescribed him AAA, a brand-name drug which was included in the Lewinsky's formulary; BBB, a non-formulary drug; and CCC, a generic dr
From the following choices, choose the definition that best matches the term Screening
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further investigation of a claim. In an automated claims processing system, these criteria may signal the need for further review when, for example
A public employer, such as a municipality or county government would be considered which of the following?
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 sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. Specialty services that have certain characteristics are generally good candidates for health pl
General HMO is building a provider network and is considering Universal Hospital as an addition to its network. Minimum requirements that General should consider in determining whether Universal is qualified to participate in General's network include A.
Janet Riva is covered by a traditional 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.
Many of the credentialing standards and criteria used by health plans are often taken from already existing standards established by
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
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
One way that MCOs involve providers in risk sharing is by retaining a percentage of the providers' payment during a plan year. At the end of the plan year, the MCO may use the amount retained to offset or pay for any cost overruns for referral or hospital
One true statement regarding ethics and laws is that the values of a community are reflected in
The Azure Group is a for-profit health plan that operates in the United States. The Fordham Group owns all of Azure's stock. The Fordham Group's sole business is the ownership of controlling interests in the shares of other companies. This information ind
One way in which health plans differ from traditional indemnity plans is that health plans typically
One distinction that can be made between a staff model HMO and a group model HMO is that, in a staff model HMO, participating physicians are Back to Top
Patrick Flaherty's employer has contracted to receive healthcare for its employees from the Abundant Healthcare System. Mr. Flaherty visits his primary care physician (PCP), who sends him to have some blood tests. The PCP then refers Mr. Flaherty to a special
One ethical principle in health plans is the principle of non-malfeasance, which holds that health plans and their providers:
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
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 of the distinguishing characteristics of healthcare marketing is that many of the markets for health plans are national, not local markets.
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. Advances in computer technology have revolutionized the processing of medical and drug claims. Claims processing i
Member satisfaction is a critical element of a health plan's quality management program. A health plan can obtain information about member satisfaction with various aspects of the health plan from
One typical characteristic of an integrated delivery system (IDS) is that an IDS.
The Citywide Health Group is a large provider-based health plan that includes physician groups, hospitals, and other facilities. In order to oversee and manage the operation of the organization, Citywide has established an enterprise scheduling system. The
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
Phoebe Urich is covered by a traditional indemnity health insurance plan that specifies a $500 calendar-year deductible and includes a 20% coinsurance provision. When Ms. Urich was hospitalized, she incurred $3,000 in medical expenses that were covered by
Natalie Chan is a member of the Ultra Health Plan. Whenever she needs non-emergency 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. Craig referred h
The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to be
One ethical principle in managed care is the principle of justice/equity, which specifically holds that MCOs and their providers have a duty to
One component of information systems used by health plans incorporates membership data and information about provider reimbursement arrangements and analyzes transactions according to contract rules. This information system component is known as
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
The Venus Hospital provides medical care to paying patients, as well as to people who either have no healthcare coverage and cannot pay for the care by themselves or who receive services at reduced rates because they are covered under government sponsored
When determining physicians' fee reimbursements, the Blossom Managed Healthcare Group assigns a weighted value to each medical procedure or service and multiplies the weighted value by a money multiplier, as shown below:
Weighted value for service × Money
The Titanium Health Plan and a third-party administrator (TPA) have entered into a TPA agreement with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. One of the TPA's
The health plan determines what it considers to be the acceptable fee for a service or procedure and the physician agrees to accept that amount as payment in full for the procedure
One of the most influential pieces of legislation in the advancement of health plans within the United States was the Health Maintenance Organization (HMO) Act of 1973. One of the provisions of the Act was that it
The existing committees at the Majestic Health Plan, a health plan that is subject to the requirements of HIPAA, include the Executive Committee and the Corporate Compliance Committee. The Executive Committee serves as a long-term advisory body on issues
Phillip Tsai is insured by both a traditional 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
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
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
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
The criteria used to identify and measure healthcare quality are generally divided into three categories: structure, process, and outcomes measures. Structure measures, which relate to the nature and quality of the resources that a health plan has available
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.
Federal legislation has placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level.
This federal legislation is the
Federal Employee Health Benefits Program (FEHBP) requires health plans offering services to federal employees and their dependents to provide
In response to the demand for a method of assessing outcomes, accrediting organizations and other government and commercial groups have developed quantitative measures of quality that consumers, purchasers, regulators, and others can use to compare health
In assessing the potential degree of risk represented by a proposed insured, a health underwriter considers the factor of anti selection. Anti selection can correctly be defined as the
Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.
During the risk assessment process for a traditional indemnity group insurance health plan, group underwriters consider such characteristics as a group’s geographic location, the size and gender mix of the group, and the level of participation in the grou
Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Whenever Mr. Murray receives a health claim from a plan member, he reviews the claim
Beginning in the early 1980s, several factors contributed to increased demand for behavioral healthcare services. These factors included
HMOs typically employ several techniques to manage provider utilization and member utilization of medical services. One technique that an HMO uses to manage member utilization is
In accounting terminology, the items of value that a company owns—such as cash, cash equivalents, and receivables—are generally known as the company's
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
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy
Health plans may use different capitation arrangements for different levels of service. One typical capitation arrangement provides a capitation payment that may include primary care only, or both primary and secondary care, but not ancillary services. The
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
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
Eleanor Giambi is covered by a typical 24-hour managed care program. One characteristic of this program is that it:
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
Ed O'Brien has both Medicare Part A and Part B coverage. He also has coverage under a PBM plan that uses a closed formulary to manage the cost and use of pharmaceuticals. Recently, Mr. O'Brien was hospitalized for an aneurysm. Later, he was transferred by
Types of alternative care centers include urgent care centers, observation care units, and stepdown units. One difference between the costs associated with alternative care centers is that, compared to the cost of:
Which of the following is(are) CORRECT?
(A) Staff model HMOs can achieve maximum economies of scale but are heavily capital intensive.
(B) Staff model HMOs are closed panel.
(C) Staff model HMOs operate out of ambulatory care facilities.
Which of the following people would be considered part of the individual market segment?
The following statements are about concepts related to the underwriting function within a health plan. Select the answer choice containing the correct statement.
The Granite Health Plan is a coordinated care plan (CCP) that participates in the Medicare+Choice program. This information indicates that Granite
The scandent Health Group contracted with the Empire Corporation to provide behavioral healthcare services to.
Empire employees. As a condition of providing behavioral healthcare services, scandent required Empire to contract with scandent for basic medical services scandent's actions constituted the type of antitrust violation known as a
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).
Which of the following is an example of physician only model of operational integration?
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 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 highest and lowest rates that a health plan charges small groups, to a particular ratio.
According to the Model Act, for example, if the lowest rate an HMO charges a small group for a given set of medical benefits is $40, then the maximum rate the HMO can charge for the same set of benefits is
The following statements are about federal laws that affect healthcare organizations. Select the answer choice containing the correct response.
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
The parties to the contractual relationship that provides Castle's group health coverage to Knoll employees are
The NAIC designed a small group model law to enable small groups to obtain accessible, yet affordable, group health benefits. Specifically, the model law limits the rate spread. According to this model law, if the lowest rate that an HMO charges a small g
The following statements are about information management in health plans. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:
Calculate the hospital bed days per 1000 members for the Month to date (MTD) on 25 April, with plan membership of 25,000 and total gross hospital bed days in MTD is 300 for an XYZ Health plan?
TESTED 02 May 2026