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Question 1:

Brokers are one type of distribution channel that health plans use to market their health plans. One true statement about brokers for health plan products is that, typically, brokers

A. Are not required to be licensed by the states in which they market health plans

B. Are compensated on a salary basis

C. Represent only one health plan or insurer

D. Are considered to be an agent of the buyer rather than an agent of the health plan or Insurer

Correct Answer: D

Question 2:

Before the Hill 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

A. Hill had to have an initial net worth of at least $1.5 million in order to obtain a COA.

B. The COA most likely exempts Hill from any of State X\’s enabling statutes.

C. Hill had to be organized as a partnership in order to obtain a COA

D. The COA in no way indicates that Hill has demonstrated that it is fiscally sound.

Correct Answer: A

Question 3:

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.

A. All members of Holcomb HMO must select Dr. Phram as their primary care physician (PCP).

B. Any physician who meets Holcomb\’s standards of care is eligible to contract with Holcomb HMO as a provider.

C. Dr. Phram is either an employee of Holcomb HMO or belongs to a group of physicians that has contracted with Holcomb HMO

D. Holcomb HMO plan members may self-refer to Dr. Phram at full benefits without first obtaining a referral from their PCPs.

Correct Answer: A

Question 4:

As part of its quality management program, the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. When Lyric concludes that its competitor\’s practices or services are better than its own, Lyric im

A. Benchmarking.

B. Standard of care.

C. An adverse event.

D. Case-mix adjustment.

Correct Answer: A

Question 5:

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

A. A, B, C, and D

B. A and C only

C. A, B, and D only

D. B, C, and D only

Correct Answer: A

Question 6:

A public employer, such as a municipality or county government would be considered which of the following?

A. Employer-employee group

B. Multiple-employer group

C. Affinity group

D. Debtor-creditor group

Correct Answer: A

Question 7:

A physician-hospital organization (PHO) may be classified as an open PHO or a closed PHO. With respect to a closed PHO, it is correct to say that

A. the specialists in the PHO are typically compensated on a capitation basis

B. the specialists in the PHO are typically compensated on a capitation basis

C. it typically limits the number of specialists by type of specialty

D. it is available to a hospital\’s entire eligible medical staff

E. physician membership in the PHO is limited to PCPs

Correct Answer: B

Question 8:

All CDHP products provide federal tax advantages while allowing consumers to save money for their healthcare.

A. True

B. False

Correct Answer: A

Question 9:

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

A. Confinement in the extended-care facility after his hospitalization.

B. Transportation by ambulance from the hospital to the extended-care facility.

C. Physicians\’ professional services while he was hospitalized.

D. physicians\’ professional services while he was at the extended-care facility.

Correct Answer: A

Question 10:

Following a report by the Institute of Medicine on the incidence and consequences of medical errors, a national task force recommended implementation of a nationwide mandatory system of collecting, analyzing, and reporting standardized information about m

A. random change

B. structural change

C. haphazard change

D. reactive change

Correct Answer: D

Question 11:

In the following sections, we will describe some of the measures health plans use to evaluate the quality of the services and healthcare they offer their members.

Which of the following is the best description of what a \’Process measure\’ evaluates?

A. The nature, quantity, and quality of the resources that a health plan has available for member service and patient care.

B. The methods and procedures a health plan and its providers use to furnish service and care.

C. The extent to which services succeed in improving or maintaining satisfaction and patient health.

D. None of the above

Correct Answer: B

Question 12:

Immediate evaluation and treatment of illness or injury can be provided in any of the following care settings:

A. Hospital emergency departments

B. Physician\’s offices

C. Urgent care centers

D. If these settings are ranked in order of the cost of providing c

A. A, B, C

B. A, C, B

C. B, C, A

D. C, A, B

Correct Answer: B

Question 13:

In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known

A. dual choice

B. cost shifting

C. accreditation

D. defensive medicine

Correct Answer: B

Question 14:

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.

A. Such intervention can be based on the results of

B. Prospective review

C. Concurrent review

A. A, B, and C

B. A and B only

C. A and C only

D. B only

Correct Answer: B

Question 15:

Bart Vereen is insured by both a traditional indemnity health insurance plan, which is his primary plan, and a managed care plan. Both plans have a typical coordination of benefits (COB) provision, but neither plan has a nonduplication of benefits provision

A. 380

B. 130

C. 0

D. 550

Correct Answer: A

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