Network Management v4.0

The Omni Health Plan is interested in expanding the specialty services it offers to its plan members and is considering contracting with the following providers of specialty services:
The Apex Company, a managed vision care organization (MVCO)
The Baxter Managed Behavioral Healthcare Organization (MBHO)
The Cheshire Dental Health Maintenance Organization (DHMO)
As part of its credentialing process, Omni would like to verify that each of these providers has met NCQAs accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for

The Brice Health Plan submitted to Clarity Health Services a letter of intent indicating
Brices desire to delegate its demand management function to Clarity. One true statement about this letter of intent is that it

Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in

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

Most health plan contracts provide an outline of the criteria that a healthcare service must meet in order to be considered medically necessary. Typically, in order for a healthcare service to be considered medically necessary, the service provided by a physician or other healthcare provider to identify and treat a members illness or injury must be

From the following answer choices, choose the type of clause or provision described in this situation.
The provider contract between Dr. Olin Norquist and the Granite Health Plan specifies a time period for the party who has breached the contract to remedy the problem and avoid termination of the contract.

The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline.
Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumns PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumns dermatology services fund for the first quarter was $15,000. During the quarter, Autumns PCPs made 90 referrals, and 20 of these referrals were classified as complicated.
Autumns method of reimbursing specialty providers can best be described as a

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.
In most states, a health plan can be held responsible for a providers negligent malpractice.
This legal concept is known as (vicarious liability / risk sharing). One step that health plans can take to reduce their exposure to malpractice lawsuits is to state in health plan-provider agreements,marketing collateral, and membership literature that the providers are
(employees of the health plan / independent contractors).

The following statements are about incentive programs used for providers. Select the answer choice containing the correct statement.

One reimbursement method that health plans can use for hospitals is the ambulatory payment classifications (APCs) method. APCs bear a resemblance to the diagnosis-related groups (DRGs) method of reimbursement. However, when comparing APCs and DRGs, one of the primary differences between the two methods is that only the APC method

An health plan enters into a professional services capitation arrangement whenever the health plan

With respect to contractual provisions related to provider-patient communications, nonsolicitation clauses prohibit providers from

The following statement(s) can correctly be made about the TRICARE managed healthcare program of the U.S. Department of Defense.
1. Active-duty military personnel are automatically enrolled in TRICAREs HMO option
(TRICARE Prime).
2. Eligible family members and dependents can enroll in TRICARE Prime, the PPO plan
(TRICARE Extra), or an indemnity plan (TRICARE Standard).

One type of fee schedule payment system assigns a weighted unit value for each medical procedure or service based on the cost and intensity of that service. Under this system, the unit values for procedural services are generally higher than the unit values for cognitive services. This system is known as a