Question 12 pts True or False: State departments of insurance review managed car

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Question 12 pts

True or False: State departments of insurance review managed care organizations for network adequacy. The requirements for network adequacy vary by state.

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Question 22 pts

Which of the following is not an example of a specific, quantitative standard for network adequacy?

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Question 32 pts

If an insurer is looking to enter an insurance market for the first time and needs to set up a provider network quickly, they should use:

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Question 42 pts

True or False: An IPA is a legal entity that contracts with physicians and in turn contracts with a health plan.

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Question 52 pts

Which of the following has been "dubbed" the "medical neighborhood" because it is made up of many medical homes?

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Question 62 ptsSkip to question text.

True or False: An advantage to a managed care plan in contracting with a large medical group or IPA is that it takes less time and effort to build a network. This is because of the efficiency of signing a single contract as opposed to many physician contracts individually.

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Question 72 pts

Which of the following has the least leverage during contract negotiations with managed care organizations?

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Question 82 ptsSkip to question text.

Which of the following terms best describes "an organized group of providers that coordinates the care for designated beneficiaries in the traditional Medicare FFS program and that will participate in a shared savings program?" These entities are more likely to be facility-based, though not exclusively so.

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Question 92 pts

True or False: One of the current provider network issues that is currently being debated is whether regulators should approve narrow networks to keep consumer premiums affordable.

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Question 102 ptsSkip to question text.

True or False: In response to the consumer and provider backlash against the tightly managed provider networks that proliferated in the 1990s, some states enacted laws intended to restrict the ability of managed care insurers to selectively contract with providers. "Any willing provider" (AWP) and "freedom of choice" (FOC) laws are examples of these state laws.

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Question 112 pts

True or False: The trends of provider and hospital consolidation will likely reduce healthcare costs.

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Question 122 pts

True or False: An out-of-network provider is one that participates, has negotiated a lower rate for services and/or is in-network with an insurer.

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Question 132 pts

True or False: Members of managed care organizations who visit a Tier 1 hospital typically have higher copayments than if they visited a Tier 2 hospital.

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Question 142 pts

True or False: Managed care organizations that use hospital tiering "drive" members to certain tiers of hospitals by reducing copayments.

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Question 152 pts

True or False: Physicians are typically re-credentialed every 10 years.

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Question 162 pts

Basic elements of credentialing include which of the following?

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Question 172 pts

True or False: The NPDB electronically stores information about physician malpractice suits and disciplinary actions upon physicians.

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Question 182 pts

True or False: Fee-for-service is always a form of prospective payment.

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Question 192 pts

Which of the following does not describe UCR charges?

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Question 20 2 pts

True or False: An allowable fee (or allowed charge) is the lowest amount the payer is willing to pay providers for services.

Question 21 2 pts

Which of the following statements is an argument against using capitation?

Question 22 2 pts

True or False: Most capitated physicians are also paid through FFS by other payers.

Question 23 2 pts

Which of the following is not a common hospital payment type?

Question 24 2 pts

Which of the following terms best describes a hospital's list of prices for each procedure performed, and supply item used, in the hospital?

Question 25 2 pts

True or False: A payment withhold can be used in FFS or capitation.

Explanation / Answer

12. The answer is "true". Several recent state statutes specific to exchanges set standards that are related to network adequacy. For example Kentucky requires managed care plans to demonstrate network adequacy through quantifiable criteria, whereas Montana states that managed care plans should maintain a network that is sufficient in numbers and types of providers to ensure that all services to covered persons are accessible without unreasonable delay.

22. The answer is the first option - "Reasonable access without delay". Quantitative standards include a minimum number of providers, maximum travel time, and maximum travel distance per county for all provider types covered under the plan contract.

32. Provider network include the doctors, clinics, hospitals etc that are included in the insurance plan. Insurer should use "retail clinics". These clinics offer low cost and basic primary care treatment and diagnostic services. These clinics are found both in urban/sub urban areas as well as rural and underserved communities.

42. IPA or independent physician association consists of a panel of physicians who contract with health plans and hospitals to provide complete care to members of Health Maintenance Organizations (HMO). So the answer is "true".

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