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Most contracts between health plans and providers contain a provision which forbids providers from seeking compensation from patients if the health plan fails to compensate the provider because of insolvency or for any other reason. Such a provision is kn

A.

due process provision

B.

cure provision

C.

hold-harmless provision

D.

risk-sharing provision

Some providers use electronic medical records (EMRs) to document their patients' care in an electronic form. The following statement(s) can correctly be made about EMRs:

A.

EMRs are computerized records of a patient's clinical, demographic, and administrator

B.

B only

C.

Both A and B

D.

Neither A nor B

E.

A only

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:

A.

Active duty military personnel are automatically considered enrolled in TRICARE Prime

B.

TRICARE covers inpatient and outpatient services, physician and hospital charges, and medical supplies, but not mental health services.

C.

TRICARE enrollees are not entitled to appeal authorization or coverage decisions

D.

Hospitals participating in the TRICARE program are exempt from JCAHO accreditation and Medicare certification.

Many of the credentialing standards and criteria used by health plans are often taken from already existing standards established by

A.

the National Practitioner Data Bank (NPDB)

B.

the National Association of Insurance Commissioners (NAIC)

C.

the Centers for Medicare and Medicaid Services (CMS)

D.

independent accrediting organizations

One non-group market segment to which health plans market health plan products is the senior market, which is comprised mostly of persons over age 65 who are eligible for Medicare benefits. One factor that affects a health plan's efforts to market to the

A.

The Centers for Medicare and Medicaid Services (CMS) must approve all marketing materials used by health plans to market health plan products to the Medicare population

B.

managed Medicare plans typically require Medicare beneficiaries to purchase Medigap insurance to supplement gaps in coverage

C.

managed Medicare plans can refuse to cover persons with certain health problems

D.

the CMS prohibits health plans from using telemarketing to market health plan products to the Medicare population

Provider integration has two components: operational integration and structural integration. An example of operational integration in health plans is the:

A.

Acquisition of the Leopard Health Plan by the Hickory Health Plan.

B.

Joint venture entered into by the Eclipse Health Plan and a local hospital system to create a new health plan in which Eclipse and the hospital system share ownership.

C.

Formation of an organization by a group of providers to carry out billing, collections, and contracting with health plans for the entire group of providers.

D.

Consolidation of the Carver Health Plan and the Limestone Health Plan.

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

A.

Within Ultra's system, Ms. Chan received primary care from both Dr. Craig and Dr. Lee.

B.

Ultra's system allows its members open access to all of Ultra's participating providers.

C.

Within Ultra's system, Dr. Craig serves as a coordinator of care or gatekeeper for the medical services that Ms. Chan receives.

D.

Ultra's network of providers includes Dr. Craig and Dr. Lee but not Arrow Hospital.

A health savings account must be coupled with an HDHP that meets federal requirements for minimum deductible and maximum out-of-pocket expenses. Dollar amounts are indexed annually for inflation. For 2006, the annual deductible for self-only coverage must

A.

$525

B.

$1,050

C.

$2,100

D.

$5,250

In order to measure the expenses of institutional utilization, Holt Healthcare Group uses the standard formula to calculate hospital bed days per 1,000 plan members per year. On October 23, Holt used the following information to calculate the bed days per

A.

278

B.

397

C.

403

D.

920

Although the process is voluntary for health plans, external accreditation is becoming more and more important as states and purchasers require health plans undergo as many states and purchasers require health plans undergo some type of external review pr

A.

Is voluntary for health plans.

B.

Requires all change accreditation organizations to use the same standards of accreditation.

C.

Typically requires the accrediting organization to conduct a medical record review and a review of a health plan's credentialing processes, but not an evaluation of the health plans' member service systems processes.

D.

Cannot assure that a health plan meets a specified level of quality.