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AHM-530 – Network Management

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Showing 13–15 of 15 questions

Question 13 (Volume B)

The employees of the Trilogy Company are covered by a typical workers' compensation program. Under this coverage, Trilogy employees are bound by the exclusive remedy doctrine, which most likely:

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    Allows Trilogy to deny benefits for an employee's on-the-job injury or illness, but only if Trilogy is not at fault for the injury or illness.
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    Allows Trilogy to place limits on the amount of coverage payable for a given claim under the workers' compensation program.
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    Requires the employees to accept workers' compensation as their only compensation in cases of work-related injury or illness.
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    Provides the employees with 24-hour coverage.
Question 14 (Volume B)

Dr. Sylvia Cimer and Dr. Andrew Donne are obstetrician/gynecologists who participate in the same provider network. Dr. Comer treats a large number of high-risk patients, whereas Dr. Donne’s patients are generally healthy and rarely present complications. As a result, Dr. Comer typically uses medical resources at a much higher rate than does Dr. Donne. In order to equitably compare Dr. Comer’s performance with Dr. Donne’s performance, the health plan modified its evaluation to account for differences in the providers’ patient populations and treatment protocols. The health plan modified Dr. Comer’s and Dr. Donne’s performance data by means of

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    A case mix/severity adjustment

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    An external performance standard

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    Structural measures

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    Behavior modification
Question 15 (Volume A)

The actual number of providers included in a provider network may be based on staffing ratios. Staffing ratios relate the number of

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    Potential providers in a plan’s network to the number of individuals in the area to be served by the plan

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    Providers in a plan’s network to the number of enrollees in the plan

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    Providers outside a plan’s network to the number of providers in the plan’s network

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    Support staff in a plan’s network to the number of medical practitioners in the plan’s network