AHIP AHM-530 Quiz 1 Topic 1 Questions 1-5

Question: 1

Dr. Sylvia Cimer and Dr. Andrew Donne are obstetrician/gynecologists who participate in the same provider network. Dr. Comer treats a large number of high-risk patients, whereas Dr. Donne's patients are generally healthy and rarely present complications. As a result, Dr. Comer typically uses medical resources at a much higher rate than does Dr. Donne. In order to equitably compare Dr. Comer's performance with Dr. Donne's performance, the health plan modified its evaluation to account for differences in the providers' patient populations and treatment protocols. The health plan modified Dr. Comer's and Dr. Donne's performance data by means of

AAcase mix/severity adjustment

BAn external performance standard

CStructural measures

DBehavior modification

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Question: 2

The provider contract that the Danube Health Plan has with the Viola Home Health Services Organization states that Danube will use a typical flat rate reimbursement arrangement to compensate Viola for the skilled nursing services it provides to Danube's plan members. A portion of the contract's reimbursement schedule is shown below:

Home Health Licensed Practical Nurse (LPN): $45 per visit or $90 per diem

Home Health Registered Nurse (RN): $50 per visit or $110 per diem

Last month, an LPN from Viola visited a Danube plan member and provided 1 hours of home healthcare, and an RN from Viola visited another Danube plan member and provided 7 hours of home healthcare. The following statement(s) can correctly be made about Danube's payment to Viola for these services:

ADanube most likely owes $90 for the LPN's skilled nursing services and $110 for the RN's skilled nursing services.

BDanube's payment amount could be different from the amount called for in the reimbursement schedule if the level of care provided to one of these plan members was significantly different from the level of care normally provided by Viola's RNs and LPNs.

CBoth A and B

DA only

EB only

FNeither A nor B

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Question: 3

A provider contract describes the responsibilities of each party to the contract. These responsibilities can be divided into provider responsibilities, health plan responsibilities, and mutual obligations. Mutual obligations typically include

Aprovisions for marketing the plan's product

Bpayment arrangements between the plan and the provider

Cverification of the plan's eligibility to do business

Dmanagement of the contents of members' medical records

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Question: 4

The provider contract between the Regal Health Plan and Dr. Caroline Quill contains a type of termination clause known as termination without cause. One true statement about this clause is that it

ARequires Regal to send a report to the appropriate accrediting agency if the health plan terminates Dr. Quill's contract without cause

BRequires that Regal must base its decision to terminate Dr. Quill's contract on clinical criteria only

CAllows either Regal or Dr. Quill to terminate the contract at any time, without any obligation to provide a reason for the termination or to offer an appeals process

DAllows Regal to terminate Dr. Quill's contract at the time of contract renewal only, without any obligation to provide a reason for the termination or to offer an appeals process

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Question: 5

The following statements are about factors that health plans should consider as they develop provider networks in rural and urban markets. Three of the statements are true, and one of the statements is false. Select the answer choice that contains the FALSE statement.

ACompared to providers in urban areas, providers in rural areas are less likely to offer discounts to health plans in exchange for directed patient volume.

BIn urban areas, limiting the number of specialists on a panel usually affects the network's market appeal more than does limiting the number of primary care physicians.

CThe greatest opportunity to create competition in rural areas is among the specialty providers in other nearby communities.

DTypically, hospital contracting is easier in urban areas than in rural areas.

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AHIP AHM-530 Quiz:1 Topic:1 Questions:1-5