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Question 1.1. (TCO B) The original impetus of HMO development came from which of the following? (Points : 5)
Providers seeking patient revenues
Consumers seeking access to healthcare
Employers
All of the above
None of the above


Question 2.2. (TCO A) Key common characteristics of PPOs include _____.
(Points : 5)
selected provider panels
negotiated payment rates
consumer choice
utilization management
All of the above
A, B, and D only


Question 3.3. (TCO B) Basic elements of credentialing include _____.
(Points : 5)
hospital privileges
malpractice history
medical license
continuing medical education (CME)
All of the above
A, B, and C only


Question 4.4. (TCO D) A common financial risk arrangement used as a performance-based incentive is _____.
(Points : 5)
carve-outs
withholds
per diem
FFS


Question 5.5. (TCO B) Which of the following forms of hospital reimbursement contain no elements of risk sharing by the hospital? (Points : 5)
Capitation
DRGs
Per diem
Sliding scale FFS
Both C and D


Question 6.6. (TCO C) Common sources of information to trigger DM include _____.
(Points : 5)
claims
laboratory tests
referrals from inpatient care coordinators
pharmacy data
electronic medical records
All of the above
A through D only


Question 7.7. (TCO C) One potential negative consequence of drug formularies with high copayments is _____.
(Points : 5)
increased use of generic drugs
increased use of brand drugs
copayments may be a barrier to adherence.
decreased use of the most cost-effective medications


Question 8.8. (TCO C) Which of the following are components of a strong MCO prevention program? (Points : 5)
Member benefits
Services for members, such as health risk assessments
Contracts with providers
Public policies
A and C only
A, B, C, and D


Question 9.9. (TCO D) This federal law has established specific, enforceable regulations regarding the standardization of electronic transactions and code sets for procedures and diagnoses. (Points : 5)
OCR
HEDIS
HIPAA
EMTALA


Question 10.10. (TCO D) Employees who are engaged in their healthcare will do the following except what? (Points : 5)
Have better compliance with health intervention programs
Have lower healthcare costs
Have higher productivity
Have more direct reports


Question 11.11. (TCO D) Which of the following does HIPAA regulate? (Points : 5)
Electronic communications between payors and providers
Portability and access standards
Guaranteed renewability of group coverage
All of the above


Question 12.12. (TCO D) Which of the following clauses states that the provider agrees not to sue or assert any claims against the enrollee for services covered under the contract? (Points : 5)
Flow down clause
No-balance-billing clause
Force majeure clause
Hold-harmless clause



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