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AHIP AHM-530: Network Management

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Question 1

- (Topic 2)
Edward Patillo has established a Medicare+Choice medical savings account (MSA). This MSA will allow Mr. Patillo to:

A. Carry over any money remaining in his MSA at the end of the benefit year to the next benefit year

B. Make withdrawals at any time from the MSA, but only for medical expenses

C. Obtain payment at 100% of the Medicare allowable payment for all Medicare-covered services he receives, without having to pay any deductibles or out-of-pocket expenses

D. Make withdrawals from the MSA to meet qualified medical expenses that are not paid by his high-deductible health insurance policy, but these withdrawals are taxed as income to M

E. Patillo

Correct Answer:A

Question 2

- (Topic 2)
The provider contracts that the Indigo Health Plan has with its providers include a clause which states that Indigo's denial of payment for a certain medical procedure does not constitute a medical opinion and is not intended to interfere with the provider-patient relationship. This information indicates that Indigo's provider contracts include:

A. A business confidentiality clause.

B. A scope of services clause.

C. An informed refusal clause.

D. An exculpation clause.

Correct Answer:D

Question 3

- (Topic 1)
The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline.
Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn’s PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn’s dermatology services fund for the first quarter was $15,000. During the quarter, Autumn’s PCPs made 90 referrals, and 20 of these referrals were classified as complicated.
Autumn’s method of reimbursing specialty providers can best be described as a

A. Disease-specific arrangement

B. Contact capitation arrangement

C. Risk adjustment arrangement

D. Withhold arrangement

Correct Answer:B

Question 4

- (Topic 1)
Open panel health plans can contract with individual providers or with various provider groups when developing their networks. The following statements are about factors that an open panel health plan might consider in contracting with different types of provider organizations. Select the answer choice that contains the correct statement.

A. One limitation of contracting with multispecialty groups is that a health plan obtains only specialty consultants, but not PCPs.

B. One benefit to a health plan in contracting with an integrated delivery system (IDS) is the ability to have a network in rapid order and to enter into a new market or one that is already competitive.

C. A health plan that contracts with an individual practice association (IPA) has a greater ability to select and deselect individual physicians than when contracting directly with the providers.

D. A health plan that contracts with an IDS is able to eliminate the antitrust risk that exists when contracting with an IPA.

Correct Answer:B

Question 5

- (Topic 1)
Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be

A. $42,857

B. $56,700

C. $272,160

D. $680,400

Correct Answer:C

Question 6

- (Topic 1)
One true statement about the compensation arrangement known as the case rate system is that, under this system,

A. Providers stand to gain or lose based on the number and types of treatments used for each case

B. Providers have no incentives to take an active role in managing cost and utilization

C. Payors cannot adjust standard case rates to reflect the severity of the patient’s condition or complications that arise from multiple medical problems

D. Payors have the opportunity to benefit from the provider’s cost savings

Correct Answer:A

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