Health insurance exam 2 questions well
answered to pass
•Provider network - correct answer ✔✔is the strength of any managed care plan
•Network made up of a variety of disciplines:
-Contracted physicians
-Non-physician professionals
-Facilities
-Providers of ancillary and therapeutic services
-Medical vendors
•Common types of providers and organizational structures:
-Professionals providing healthcare, with main focus on physicians
-Inpatient facilities
-Ambulatory facilities (outpatient surgery centers
-Integrated health delivery systems (IDS)
Contracts and Contracting - correct answer ✔✔•Contracts legally binding documents that
define terms, conditions, and obligations of both parties
•Payers find their own networks and maintain records at local or regional level; may use rental
networks
•Contracts voluntary agreement on both sides
•Most providers have multiple contracts with payers plus Medicare and Medicaid
•See Table 3.1 in text for examples of payer/provider reasons for contracting
Basic Elements of a Typical Provider - correct answer ✔✔•Contract spells out the specifics of
the agreement
,-Some elements are not expected to change; some may be subject to frequent changes and
may be negotiated or replaced without affecting the other components of the contract
•Definitions
-Define terms that are used in the contract and typically include the following:
•Type of health plan using the contract like HMOS and PPOS
•Type of provider agreeing to the contract
•Plan components ( who's a memeber or the prescriber what are the charateristics of the
medical provider)
•Services to be provided
•Services that will not be provided
•Other medical services ( necessary care emergent care, experimental treatment, non covered
services)
Qualifications and Credentials for contracts/contracting - correct answer ✔✔•Contract
describes what qualifications and credentials the providers maintain in order to participate in
the plan; will not change over time ( provider must always maintain a current unrestricted
license )
•Provider must maintain current, unrestricted license; maintain compliance/qualification/and
credentialing requirements
Compliance with Utilization and Quality Management Programs
•Contract describes requirements that the provider must comply with utilization management
(UM) and quality management (QM) programs
•Describes the payer's responsibilities under both programs
Direct and Timely Payment
•Sets requirements for how quickly a claim is processes that did not need additional
information or problems with the claim submission
•Requires payer to pay provider directly
,Hold Harmless and No Balance Billing - correct answer ✔✔•Contract contains a no balance
clause describing the provider's agreement to accept what the plan pays as payment in full for
services provided to the patient
•Provider agrees not to bill the patient for the difference between what the plan pays and what
the provider charges
•HMOs and some PPOs include a clause stating the provider cannot bill the patient if the plan
does not pay the fee for services at all
•Provider can bill patient for copayment, coinsurance, or deductible
•No balance clause required by state and federal regulatory agencies
Payment
•Contract includes a statement that the plan will pay the provider according to the contract
•Method and amounts of payment are also included
Other-Party Liability and Coordination of Benefits - correct answer ✔✔•Coordination of
benefits rules define which plan will be considered the primary payer and which will be the
secondary payer, if more than one payer is responsible for medical services
•Partly liability rules determine when a different type of insurance plan is responsible for paying
medical services instead of the health insurance plan ( for example both of your parents have
insurance one parents insurance is the primary insurance and then the other parents insurance
covers the rest)
Right to Audit
•Contract gives the plan the right to audit medical records and bills for a specific reason ( for
example if in a car accident car health insurance will cover it not health insurance)
•May be performed for clarifying medical charges, QM compliance ( might be used to confirm
that the provider is complying with the quality management programs)(quality management
programs: quality
management audits are usually confined to
medical records of only the members and are usually focused on the primary care providers
office visit for specific conditions)
, Term and Termination - correct answer ✔✔Term and Termination
•Contract defines when the agreement begins and when it ends
-Payers may have to provide the reason for terminating the provider ( the payer may have to
provide some significant evidence of why they want to terminate that provider, and in some
states the
provider may be allowed to dispute and the termination
contracts will define under what circumstances the contract would be immediately terminated.)
-Provider may be allowed to dispute the termination in some states
-Contract defines when termination can occur immediately
-Define time frame for a newly trained specialist to obtain board certification
Nondiscrimination
•Provider may not discriminate against a plan member
•Non-discrimination clause similar to civil rights
Attachments or Appendices
•Contract terms and conditions that may change are included in the contract in attachments or
appendices
•When changes occur, only the attachment or appendix has to be replaced; not the entire
contract
Service Areas, Access to Standard, and Network Adequacy - correct answer ✔✔A plan's service
area is the geographic area the plan meets its provider access requirements
•A service area is an expression of network adequacy requirements, meaning:
-Service areas apply primarily to HMOs, Medicare Advantage, and managed Medicaid plans
-Ensures access to primary/specialty care, hospital/emergency care, other services
-Plan is not allowed to market and sell outside of its service area, but can and do recruit
providers outside of it
•Because access is measured only for practices accepting new patients, the plan must monitor
how many practices are open for each zip code, drive time, etc.
answered to pass
•Provider network - correct answer ✔✔is the strength of any managed care plan
•Network made up of a variety of disciplines:
-Contracted physicians
-Non-physician professionals
-Facilities
-Providers of ancillary and therapeutic services
-Medical vendors
•Common types of providers and organizational structures:
-Professionals providing healthcare, with main focus on physicians
-Inpatient facilities
-Ambulatory facilities (outpatient surgery centers
-Integrated health delivery systems (IDS)
Contracts and Contracting - correct answer ✔✔•Contracts legally binding documents that
define terms, conditions, and obligations of both parties
•Payers find their own networks and maintain records at local or regional level; may use rental
networks
•Contracts voluntary agreement on both sides
•Most providers have multiple contracts with payers plus Medicare and Medicaid
•See Table 3.1 in text for examples of payer/provider reasons for contracting
Basic Elements of a Typical Provider - correct answer ✔✔•Contract spells out the specifics of
the agreement
,-Some elements are not expected to change; some may be subject to frequent changes and
may be negotiated or replaced without affecting the other components of the contract
•Definitions
-Define terms that are used in the contract and typically include the following:
•Type of health plan using the contract like HMOS and PPOS
•Type of provider agreeing to the contract
•Plan components ( who's a memeber or the prescriber what are the charateristics of the
medical provider)
•Services to be provided
•Services that will not be provided
•Other medical services ( necessary care emergent care, experimental treatment, non covered
services)
Qualifications and Credentials for contracts/contracting - correct answer ✔✔•Contract
describes what qualifications and credentials the providers maintain in order to participate in
the plan; will not change over time ( provider must always maintain a current unrestricted
license )
•Provider must maintain current, unrestricted license; maintain compliance/qualification/and
credentialing requirements
Compliance with Utilization and Quality Management Programs
•Contract describes requirements that the provider must comply with utilization management
(UM) and quality management (QM) programs
•Describes the payer's responsibilities under both programs
Direct and Timely Payment
•Sets requirements for how quickly a claim is processes that did not need additional
information or problems with the claim submission
•Requires payer to pay provider directly
,Hold Harmless and No Balance Billing - correct answer ✔✔•Contract contains a no balance
clause describing the provider's agreement to accept what the plan pays as payment in full for
services provided to the patient
•Provider agrees not to bill the patient for the difference between what the plan pays and what
the provider charges
•HMOs and some PPOs include a clause stating the provider cannot bill the patient if the plan
does not pay the fee for services at all
•Provider can bill patient for copayment, coinsurance, or deductible
•No balance clause required by state and federal regulatory agencies
Payment
•Contract includes a statement that the plan will pay the provider according to the contract
•Method and amounts of payment are also included
Other-Party Liability and Coordination of Benefits - correct answer ✔✔•Coordination of
benefits rules define which plan will be considered the primary payer and which will be the
secondary payer, if more than one payer is responsible for medical services
•Partly liability rules determine when a different type of insurance plan is responsible for paying
medical services instead of the health insurance plan ( for example both of your parents have
insurance one parents insurance is the primary insurance and then the other parents insurance
covers the rest)
Right to Audit
•Contract gives the plan the right to audit medical records and bills for a specific reason ( for
example if in a car accident car health insurance will cover it not health insurance)
•May be performed for clarifying medical charges, QM compliance ( might be used to confirm
that the provider is complying with the quality management programs)(quality management
programs: quality
management audits are usually confined to
medical records of only the members and are usually focused on the primary care providers
office visit for specific conditions)
, Term and Termination - correct answer ✔✔Term and Termination
•Contract defines when the agreement begins and when it ends
-Payers may have to provide the reason for terminating the provider ( the payer may have to
provide some significant evidence of why they want to terminate that provider, and in some
states the
provider may be allowed to dispute and the termination
contracts will define under what circumstances the contract would be immediately terminated.)
-Provider may be allowed to dispute the termination in some states
-Contract defines when termination can occur immediately
-Define time frame for a newly trained specialist to obtain board certification
Nondiscrimination
•Provider may not discriminate against a plan member
•Non-discrimination clause similar to civil rights
Attachments or Appendices
•Contract terms and conditions that may change are included in the contract in attachments or
appendices
•When changes occur, only the attachment or appendix has to be replaced; not the entire
contract
Service Areas, Access to Standard, and Network Adequacy - correct answer ✔✔A plan's service
area is the geographic area the plan meets its provider access requirements
•A service area is an expression of network adequacy requirements, meaning:
-Service areas apply primarily to HMOs, Medicare Advantage, and managed Medicaid plans
-Ensures access to primary/specialty care, hospital/emergency care, other services
-Plan is not allowed to market and sell outside of its service area, but can and do recruit
providers outside of it
•Because access is measured only for practices accepting new patients, the plan must monitor
how many practices are open for each zip code, drive time, etc.
