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Arthur Dace, a plan member of the Bloom health plan, tried repeatedly over an extended period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr. Dace informally surveyed other Bloom plan members and found that many people were experiencing similar problems getting an appointment with this particular provider. Mr. Dace threatened to take legal action against Bloom, alleging that the health plan had deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making it difficult for patients to make appointments with Dr. Pyle.

Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR) method that is quicker and less expensive than litigation. Under this ADR method, both Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who issued a decision that Bloom's utilization management practices in this case did not constitute a form of abuse. The panel's decision is legally binding on both parties.

Different types of compensation arrangements in managed care plans, from fee-for-service (FFS) arrangements to capitation arrangements, lead to different types of fraud and abuse. From the answer choices below, select the response that identifies the form of abuse in which Bloom is allegedly engaging, according to Mr. Dace's complaint, and whether this form of abuse is more likely to occur in FFS compensation arrangements or in capitation arrangements.

A.

Type of abuse underutilization

Type of compensation arrangement FFS arrangement

B.

Type of abuse underutilization

Type of compensation arrangement capitation arrangement

C.

Type of abuse overutilization

Type of compensation arrangement FFS arrangement

D.

Type of abuse overutilization

Type of compensation arrangement capitation arrangement

In the paragraph below, a statement contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the statement. Then select the answer choice containing the two terms that you have chosen.

Every employee benefit plan governed by the Employee Retirement Income Security Act (ERISA) must distribute a summary plan description (SPD) to participants within (90 / 120) days after the date on which the plan is adopted or made effective. Thereafter, if the plan is amended, a new SPD must be distributed every (5 / 10) years.

A.

90 / 5

B.

90 / 10

C.

120 / 5

D.

120 / 10

The National Association of Insurance Commissioners (NAIC) adopted the Health Maintenance Organization Model Act (HMO Model Act) to regulate the development and operations of HMOs. One true statement regarding the HMO Model Act is that the act

A.

includes mental health services in its definition of basic healthcare services

B.

authorizes only one state agency-the department of insurance-to regulate HMOs

C.

requires HMOs to place a deposit in trust with the state insurance commissioner for the purpose of protecting the interests of enrollees should an HMO become financially impaired

D.

requires HMOs that wish to offer a point-of-service (POS) product to contract with a licensed insurance company to provide POS options to plan members

Regulators of health plans have set standards in a number of areas of plan operations. Requirements with which health plans must comply typically include

A.

providing enrollees and prospective enrollees with detailed information about various aspects of health plan policies and operations

B.

maintaining internal grievance and appeals processes to resolve enrollee complaints against the organization

C.

maintaining quality assurance programs that reflect the plan's activities in monitoring quality

D.

all of the above

The Tidewater Life and Health Insurance Company is owned by its policy owners, who are entitled to certain rights as owners of the company, and it issues both participating and nonparticipating insurance policies. Tidewater is considering converting to the type of company that is owned by individuals who purchase shares of the company's stock. Tidewater is incorporated under the laws of Illinois, but it conducts business in the Canadian provinces of Ontario and Manitoba.

With regard to the state in which Tidewater is domiciled, it is correct to say that, from the perspective of both Ontario and Manitoba, Tidewater is considered to be the type of corporation known as:

A.

A foreign corporation

B.

An alien corporation

C.

A sister corporation

D.

A domestic corporation

Greenpath Health Services, Inc., an HMO, recently terminated some providers from its network in response to the changing enrollment and geographic needs of the plan. A provision in Greenpath's contracts with its healthcare providers states that Greenpath can terminate the contract at any time, without providing any reason for the termination, by giving the other party a specified period of notice.

The state in which Greenpath operates has an HMO statute that is patterned on the NAIC HMO Model Act, which requires Greenpath to notify enrollees of any material change in its provider network. As required by the HMO Model Act, the state insurance department is conducting an examination of Greenpath's operations. The scope of the on-site examination covers all aspects of Greenpath's market conduct operations, including its compliance with regulatory requirements.

The contracts between Greenpath and its healthcare providers contain a termination provision known as

A.

An 'economic credentialing' termination provision

B.

A 'breach of contract' termination provision

C.

A 'fair procedure' termination provision

D.

A 'without cause' termination provision

Congress enacted three clauses relating to the preemptive effect of the Employee Retirement Income Security Act of 1974 (ERISA). One of these clauses preserves from ERISA preemption any state law that regulates insurance, banking, or securities, with the exception of the exemption for self-funded employee benefit plans. This clause is called the

A.

Savings clause

B.

Preemption clause

C.

Deemer clause

D.

De novo clause

The Hanford Health Plan has delegated the credentialing of its providers to the Sienna Group, a credential verification organization (CVO). If the contract between Hanford and Sienna complies with all of the National Committee for Quality Assurance (NCQA) guidelines for delegation of credentialing, then this contract

A.

Transfers to Sienna all rights to terminate or suspend individual practitioners or providers in Hanford's provider network

B.

Describes the process by which Hanford evaluates Sienna's performance in credentialing providers

C.

Both A and B

D.

A only

E.

B only

F.

Neither A nor B

The Nonprofit Institutions Act allows the Neighbor Hospital, a not-for-profit hospital, to purchase at a discount drugs for its 'own use'. Consider whether the following sales of drugs were not for Neighbor's own use and therefore were subject to antitrust enforcement:

Elijah Jamison, a former patient of Neighbor, renewed a prescription that was originally dispensed when he was discharged from Neighbor.

Neighbor filled a prescription for Camille Raynaud, who has no connection to Neighbor other than that her prescribing physician is located in a nearby physician's office building.

Neighbor filled a prescription for Nigel Dixon, who is a friend of a Neighbor medical staff member.

With respect to the United States Supreme Court's definition of 'own use,' the drug sales that were not for Neighbor's own use were the sales that Neighbor made to

A.

Mr. Jamison, Ms. Raynaud, and Mr. Dixon

B.

Mr. Jamison and Ms. Raynaud only

C.

Mr. Dixon only

D.

None of these individuals

Health plans should monitor changes in the environment and emerging trends, because changes in society will affect the managed care industry. One true statement regarding recent changes in the environment in which health plans operate is that

A.

Women as a group receive more healthcare and interact more often with health plans than do men over the course of a lifetime

B.

The focus of healthcare during the past decade has shifted away from outpatient care to inpatient hospital treatment

C.

The uninsured population in the United States has been decreasing in recent years

D.

The decline in overall inflation in the 1990s failed to slow the growth in healthcare inflation