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The Ross Health Plan compensates Dr. Cecile Sanderson on a FFS basis. In order to increase the level of reimbursement that she would receive from Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The services she actually provided represented an intermediate level of service. Dr. Sanderson’s action is an example of a type of false billing procedure known as

A.

Cost shifting

B.

Churning

C.

Unbundling

D.

Upcoding

Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in

A.

Slower access to BH care for plan members

B.

Increased collaboration between BH providers and PCPs

C.

Fewer specialized BH services for plan members

D.

Decreased continuity of BH care for plan members

The following statements are about the negotiation process of provider contracting. Three of the statements are true and one of the statements is false. Select the answer choice containing the FALSE statement.

A.

While preparing for negotiations, the health plan usually sends the provider an application to join the provider network, a list of credentialing requirements, and a copy of the proposed provider contract, which may or may not include the proposed reimbursement schedule.

B.

In general, the ideal negotiating style for provider contracting is a collaborative approach.

C.

Typically, the health plan and the provider negotiate the reimbursement arrangement between the parties before they negotiate the scope of services and the contract language.

D.

The actual signing of the provider contract typically takes place after negotiations are completed.

In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it

A.

Applies to group health insurance plans only

B.

Limits the length of a health plan’s pre-existing condition exclusion period for a previously covered individual to a maximum of six months after enrollment.

C.

Guarantees access to healthcare coverage for small businesses and previously covered individuals who meet specified eligibility requirements.

D.

Guarantees renewability of group and individual health coverage, provided the insureds are still in good health

The Sweeney Health Plan uses the discounted fee-for-service (DFFS) method to compensate some of its providers. Under this method of compensation, Sweeney calculates payments based on

A.

The standard fees of indemnity health insurance plans, adjusted by region

B.

The Medicare fee schedules used by other health plans, adjusted by region

C.

Whichever amount is higher, the billed charge or the DFFS amount

D.

Whichever amount is lower, the billed charge or the DFFS amount

Although a health plan is allowed to delegate many activities to outside sources, the National Committee for Quality Assurance (NCQA) has determined that some activities are not delegable.

These activities include

A.

evaluation of new medical technologies

B.

overseeing delegated medical records activities

C.

developing written statements of members’ rights and responsibilities

D.

all of the above

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

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.

One statement that can correctly be made about Gardenia’s two-level POS product is that

A.

members who self-refer without first seeing their PCPs will receive no benefits

B.

both Gardenia and the PCPs stand to benefit if the non-provider panels are kept relatively narrow

C.

members will pay higher coinsurance or copayments if they first see their PCPs each time

D.

the plan offers no financial incentives to members to choose an in-network specialist over a non-network specialist

The provider contract between the Ocelot Health Plan and Dr. Enos Zorn, one of the health plan’s participating providers, is a brief contract which includes, by reference, an Ocelot provider manual. This manual contains much of the information found in Ocelot’s comprehensive provider contracts. The following statements are about Dr. Zorn’s provider contract. Select the answer choice containing the correct statement.

A.

All statements in the provider contract shall be deemed to be warranties, because all statements of facts contained in the contract must be true only in those respects material to the contract.

B.

Because the provider manual is part of the contract, Ocelot must make sure that its provider manual is comprehensive and up-to-date.

C.

Because the provider contract is a brief contract, Ocelot most likely is prohibited from amending the contract unilaterally, even if it gives Dr. Zorn advance notice of its intent to amend the contract.

D.

Areas that should be covered in the provider manual, and not in the body of the contract, include any specific legal issues relevant to the contract.

The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.

The per diem reimbursement method will require Gladspell to pay Ellysium a

A.

Fixed rate for each day a plan member is treated in Ellysium’s subacute care facility

B.

Discounted charge for all subacute care services given by Ellysium

C.

Rate that varies depending on patient category

D.

Fixed rate per enrollee per month