QUESTION: 29 Exam Topic: 1, Volume A

The following statements are about carve-out programs. Three of these statements are true, and one statement is false. Select the answer choice containing the FALSE statement.

In the type of carve-out in which entire categories of care are administered by independent organizations, a health plan typically reimburses these organizations under an FFS contract.
Typically, a health plan will offer carved-out services to its enrollees, but will manage these services separately.
Carve-outs are services that are excluded from a capitation payment, a risk pool, or a health benefit plan.
The most rapidly growing area related to carve-outs is disease management (DM).

Answer(s): A

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QUESTION: 30 Exam Topic: 1, Volume A

The Marble Health Plan sets aside a PMPM amount for each specialty.

When a PCP in Marble's provider network refers a Marble plan member to a specialist and the specialist provides medical services to the member, the specialist begins to receive a share of those funds on a monthly basis. Marble determines the monthly payment for each specialist by dividing the number of active patients for that specialty by the total specialty pool for that month. This form of payment, which is similar to a case rate, is known as

Referral circle capitation
Risk pod capitation
Contact capitation
Retrospective reimbursement capitation

Answer(s): C

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QUESTION: 31 Exam Topic: 1, Volume A

Reconciliation is the process by which a health plan assesses providers' performance relative to contractual terms and reimbursement.

With regard to this process, it can correctly be stated that

A reconciliation typically includes payment to the providers of any withholds or bonuses due to them
A health plan typically should conduct a reconciliation immediately after the evaluation period has ended
Most agreements between health plans and providers require reconciliations to be performed quarterly
A health plan typically should not conduct reconciliation for a provider until the plan has received all claims or other documentation of services that the physician provided during the evaluation period

Answer(s): A

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QUESTION: 32 Exam Topic: 1, Volume A

With regard to capitation arrangements for hospitals, it can correctly be Back to Top stated that

The most common reimbursement method for hospitals is professional services capitation
Most jurisdictions prohibit hospitals and physicians from joining together to receive global capitations that cover institutional services provided by the hospitals
A health plan typically can capitate a hospital for outpatient laboratory and X-ray services only if the health plan also capitates the hospital for inpatient care
Many hospitals have formed physician hospital organizations (PHOs), hospital systems, or integrated delivery systems (IDSs) that can accept global capitation payments from health plans

Answer(s): D

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QUESTION: 29 Exam Topic: 1, Volume A

QUESTION: 30 Exam Topic: 1, Volume A

QUESTION: 31 Exam Topic: 1, Volume A

QUESTION: 32 Exam Topic: 1, Volume A