QUESTION: 145

One typical characteristic of preferred provider organization (PPO) benefit plans is that PPOs:

Assume full financial risk for arranging medical services for their members.
Require plan members to obtain a referral before getting medical services from specialists.
Use a capitation arrangement, instead of a fee schedule, to reimburse physicians.
Offer some coverage, although at a higher cost, for plan members who choose to use the services of non-network providers.

Answer(s): D

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QUESTION: 146

One way in which a health plan can support an ethical environment is by

requiring organizations with which it contracts to adopt the plan's formal ethical policy
developing and maintaining a culture where ethical considerations are integrated into decision making at the top organizational level only
establishing a formal method of managing ethical conflicts, such as using an ethics task force or bioethics consultant
maintaining control of policy development by removing providers and members from the process of developing and implementing policies and procedures that provide guidance to providers and members confronted with ethical issues

Answer(s): C

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QUESTION: 147

One way in which health plans differ from traditional indemnity plans is that health plans typically

provide less extensive benefits than those provided under traditional indemnity plans
place a greater emphasis on preventive care than do traditional indemnity plans
require members to pay a percentage of the cost of medical services rendered after a claim is filed, rather than a fixed copayment at the time of service as required by indemnity plans
contain cost-sharing requirements that result in more out-of-pocket spending by members than do the cost-sharing requirements in traditional indemnity plans

Answer(s): B

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One way that MCOs involve providers in risk sharing is by retaining a percentage of the providers' payment during a plan year. At the end of the plan year, the MCO may use the amount retained to offset or pay for any cost overruns for referral or hospital

withholds
usual, customary, and reasonable (UCR) fees
risk pools
per diems

Answer(s): A

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Free AHM-250 Exam Braindumps (page: 38)

QUESTION: 145

QUESTION: 146

QUESTION: 147

QUESTION: 148

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