AHM 250- INTRODUCTION TO HEALTH MANAGEMENT
(25-27 UPDATED QUESTIONS AND CORRECT
ANSWERS
Question:
1. NAIC HMO Model Act regulates HMO operations in two critical areas:
Answer:
financial responsibility and healthcare delivery
addresses financial responsibility through licensing requirements and financial standards. It addresses
healthcare delivery by establishing requirements for network adequacy, quality assurance
Question:
2. Insolvency
Answer:
occurs when an organization's assets or resources are not adequate to cover its debts and obligations.
Question:
3. Receivership
Answer:
is a situation in which the commissioner, acting for a state court, takes control of and administers an
HMO's assets and liabilities
Question:
4. The HMO Model Act focuses on three key aspects of healthcare delivery:
Answer:
• Network adequacy
• Quality assurance requirements focus on an HMO's procedures for facilitating the delivery of healthcare
services to plan enrollees.
• Grievance procedures. requires HMOs to maintain records of all complaints received by the organization
and to make these records available to the appropriate regulatory authority for review. internal process
created
Question:
5. Quality assurance
Answer:
requirements focus on an HMO's procedures for facilitating the delivery of healthcare services to plan
enrollees. HMO's quality assurance program must include a statement of the HMO's goals and objectives
for evaluating and improving enrollees' health status; documentation of all quality assurance activities; and
a system for periodically reporting program results to the HMO's board of directors, its providers, and
regulators.
Question:
6. preferred provider arrangement (PPA)
, Answer:
PPOs-Preferred provider org EPOS- exclusive provider organizations health plans that include a preferred
provider arrangement. as a contract between a healthcare insurer and a healthcare provider or group of
providers who agree to provide services to persons covered under the contract.
Question:
7. Preferred Provider Arrangement Model Act (PPA Model Act).
Answer:
This model requires PPAs to:
• clearly identify any differences in benefit levels for services of preferred providers and non-preferred
providers,
• establish the amount and manner of payment to preferred providers,
• include mechanisms for minimizing the cost of the health plan, and
• provide plan members with reasonable access to covered services.
Question:
8. Third-party administrators (TPAs
Answer:
are companies that provide administrative services to health plans, employers, or other plan sponsors.
Some of these administrative services, such as underwriting and claims, are classified as insurance
activities and as such are
-subject to state regulation
Question:
9. NAIC's Health Care Professional Credentialing Verification Model Act
Answer:
specifies requirements that health plans must satisfy to ensure that network providers meet minimum
standards of professional qualification. These requirements include the following:
• verification of the credentials of all contracted healthcare professionals in accordance with written
procedures that must be disclosed, on written request, to any applying healthcare professional;
• collection of a minimum set of credentialing information by either primary or secondary verification,
with recredentialing required every three years; and
• establishment of a process by which providers can review and correct credentialing information.
Question:
10. Quality Assessment and Improvement Model Act.
Answer:
This model requires health plans to establish and report on systems for assessing the quality of care and
services they provide. In particular, quality assessment laws require health plans to:
• establish an appropriate system for assessing the quality of healthcare services provided by each type of
network,
• report to the appropriate licensing authorities any problems that would offer grounds for provider
termination,
• file a written description of quality assessment programs with the state insurance commissioner or the
secretary of the state health department,
• describe quality programs to consumers through marketing and educational materials, and
• meet specified data confidentiality requirements.
(25-27 UPDATED QUESTIONS AND CORRECT
ANSWERS
Question:
1. NAIC HMO Model Act regulates HMO operations in two critical areas:
Answer:
financial responsibility and healthcare delivery
addresses financial responsibility through licensing requirements and financial standards. It addresses
healthcare delivery by establishing requirements for network adequacy, quality assurance
Question:
2. Insolvency
Answer:
occurs when an organization's assets or resources are not adequate to cover its debts and obligations.
Question:
3. Receivership
Answer:
is a situation in which the commissioner, acting for a state court, takes control of and administers an
HMO's assets and liabilities
Question:
4. The HMO Model Act focuses on three key aspects of healthcare delivery:
Answer:
• Network adequacy
• Quality assurance requirements focus on an HMO's procedures for facilitating the delivery of healthcare
services to plan enrollees.
• Grievance procedures. requires HMOs to maintain records of all complaints received by the organization
and to make these records available to the appropriate regulatory authority for review. internal process
created
Question:
5. Quality assurance
Answer:
requirements focus on an HMO's procedures for facilitating the delivery of healthcare services to plan
enrollees. HMO's quality assurance program must include a statement of the HMO's goals and objectives
for evaluating and improving enrollees' health status; documentation of all quality assurance activities; and
a system for periodically reporting program results to the HMO's board of directors, its providers, and
regulators.
Question:
6. preferred provider arrangement (PPA)
, Answer:
PPOs-Preferred provider org EPOS- exclusive provider organizations health plans that include a preferred
provider arrangement. as a contract between a healthcare insurer and a healthcare provider or group of
providers who agree to provide services to persons covered under the contract.
Question:
7. Preferred Provider Arrangement Model Act (PPA Model Act).
Answer:
This model requires PPAs to:
• clearly identify any differences in benefit levels for services of preferred providers and non-preferred
providers,
• establish the amount and manner of payment to preferred providers,
• include mechanisms for minimizing the cost of the health plan, and
• provide plan members with reasonable access to covered services.
Question:
8. Third-party administrators (TPAs
Answer:
are companies that provide administrative services to health plans, employers, or other plan sponsors.
Some of these administrative services, such as underwriting and claims, are classified as insurance
activities and as such are
-subject to state regulation
Question:
9. NAIC's Health Care Professional Credentialing Verification Model Act
Answer:
specifies requirements that health plans must satisfy to ensure that network providers meet minimum
standards of professional qualification. These requirements include the following:
• verification of the credentials of all contracted healthcare professionals in accordance with written
procedures that must be disclosed, on written request, to any applying healthcare professional;
• collection of a minimum set of credentialing information by either primary or secondary verification,
with recredentialing required every three years; and
• establishment of a process by which providers can review and correct credentialing information.
Question:
10. Quality Assessment and Improvement Model Act.
Answer:
This model requires health plans to establish and report on systems for assessing the quality of care and
services they provide. In particular, quality assessment laws require health plans to:
• establish an appropriate system for assessing the quality of healthcare services provided by each type of
network,
• report to the appropriate licensing authorities any problems that would offer grounds for provider
termination,
• file a written description of quality assessment programs with the state insurance commissioner or the
secretary of the state health department,
• describe quality programs to consumers through marketing and educational materials, and
• meet specified data confidentiality requirements.
