- (Topic 2)
The following statements describe two types of HMOs:
The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.
The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.
Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.
Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:
The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents
per tablet for this drug.
The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.
From the following answer choices, select the response that best identifies Elm and Treble:

1. A. Elm: open access (OA) HMO Treble: direct access HMO
2. B. Elm: open access (OA) HMO Treble: gatekeeper HMO
3. C. Elm: direct access HMO Treble: open access (OA) HMO
4. D. Elm: direct access HMO Treble: gatekeeper HMO

Correct Answer: C

- (Topic 1)
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.
If the Ellysium subacute care unit is typical of most hospital-based subacute skilled nursing units, then this unit could be used for patients who no longer need to be in the hospital’s acute care unit but who still require

1. A. Daily medical care and monitoring
2. B. Regular rehabilitative therapy
3. C. Respiratory therapy
4. D. All of the above

Correct Answer: D

- (Topic 2)
The Enterprise Health Plan has indicated an interest in delegating its medical records review activities to the Teal Group and has forwarded a typical letter of intent to Teal. One true statement about this letter of intent is that it:

1. A. Is a contract that creates a legally binding relationship between Enterprise and Teal
2. B. Cannot include a confidentiality clause
3. C. Serves as a delegation agreement between Enterprise and Teal
4. D. Outlines the delegation oversight process

Correct Answer: D

- (Topic 1)
From the following answer choices, choose the term that best matches the description.
Members of a physician-hospital organization (PHO) denied membership to a physician solely because the physician has admitting privileges at a competing hospital.

1. A. Group boycott
2. B. Horizontal division of territories
3. C. Tying arrangements
4. D. Concerted refusal to admit

Correct Answer: A

- (Topic 1)
During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider’s application. One true statement regarding this process is that the health plan

1. A. has a legal right to access a prospective provider’s confidential medical records at any time
2. B. must limit any evaluations of a prospective provider’s office to an assessment of quantitative factors, such as the number of double-booked appointments a physicianaccepts at the end of each day
3. C. is prohibited by law from conducting primary verification of such data as a prospective provider’s scope of medical malpractice insurance coverage and federal tax identification number
4. D. must complete the credentialing process before a provider signs the network contract or must include in the signed document a provision that the final contract is contingent upon the completion of the credentialing process

Correct Answer: D