QUESTION: 69

The provider contract between the Regal Health Plan and Dr. Caroline Quill contains a type of termination clause known as termination without cause. One true statement about this clause is that it

Requires Regal to send a report to the appropriate accrediting agency if the health plan terminates Dr. Quill's contract without cause
Requires that Regal must base its decision to terminate Dr. Quill's contract on clinical criteria only
Allows either Regal or Dr. Quill to terminate the contract at any time, without any obligation to provide a reason for the termination or to offer an appeals process
Allows Regal to terminate Dr. Quill's contract at the time of contract renewal only, without any obligation to provide a reason for the termination or to offer an appeals process

Answer(s): C

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The Ross Health Plan compensates Dr. Cecile Sanderson on a FFS basis. In order to increase the level of reimbursement that she would receive from Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The services she actually provided represented an intermediate level of service. Dr. Sanderson's action is an example of a type of false billing procedure known as

Cost shifting
Churning
Unbundling
Upcoding

Answer(s): D

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QUESTION: 71

The Sweeney Health Plan uses the discounted fee-for-service (DFFS) method to compensate some of its providers. Under this method of compensation, Sweeney calculates payments based on

The standard fees of indemnity health insurance plans, adjusted by region
The Medicare fee schedules used by other health plans, adjusted by region
Whichever amount is higher, the billed charge or the DFFS amount
Whichever amount is lower, the billed charge or the DFFS amount

Answer(s): D

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QUESTION: 72

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

Wrap-around payment system
Relative value scale (RVS) payment system
Resource-based relative value scale (RBRVS) system
Capped fee system

Answer(s): B

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Free AHM-530 Exam Braindumps (page: 19)

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QUESTION: 72

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