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The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:
A. Must provide Medicare participants with standard HMO benefits, as well as with limited
long-term care benefits
B. Does not need as great a variety of provider types or as complex a reimbursement method as does a traditional HMO
C. Receives a payment that is based on reasonable costs and reasonable charges
D. Most likely provides fewer supportive services than does a traditional HMO, because one of Bruin's goals is to minimize the use of community-based care
The provider contract that Dr. Bijay Patel has with the Arbor Health Plan includes a nobalance-billing clause. The purpose of this clause is to:
A. prohibit Dr. Patel from collecting payments from Arbor plan members for medical
services that he provided them, even if the services are explicitly excluded from the benefit
B. allow Dr. Patel to bill patients for services only if the services are considered to be medically necessary
C. establish the guidelines used to determine if Arbor is the primary payor of benefits in a situation in which an Arbor plan member is covered by more than one health plan
D. require Dr. Patel to accept Arbor's payment as payment in full for medical services that he provides to Arbor plan members
In health plan pharmacy networks, service costs consist of two components: costs for services associated with dispensing prescription drugs and costs for cognitive services. Cognitive services typically include:
A. making generic substitutions of drugs
B. counseling patients about prescriptions
C. providing patient monitoring
D. switching prescription drugs to preferred drugs
The following statement(s) can correctly be made about contracting and reimbursement of specialty care physicians (SCPs):
A. Typically, a health plan should attempt to control utilization of SCPs before attempting to
place these providers under a capitation arrangement.
B. Forms of specialty physician reimbursement used by health plans include a retainer and a bundled case rate.
C. Both A and B
D. A only
E. B only
F. Neither A nor B
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.
A. Cure provision
B. Hold-harmless provision
C. Evergreen clause
D. Exculpation clause
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
A. provisions for marketing the plan’s product
B. payment arrangements between the plan and the provider
C. verification of the plan’s eligibility to do business
D. management of the contents of members’ medical records
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