Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be
During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider’s application. One true statement regarding this process is that the health plan
The sizes of the businesses in a market affect the types of health programs that are likely to be purchased. Compared to smaller employers (those with fewer than 100 employees), larger employers (those with more than 1,000 employees) are
The following statements are about incentive programs used for providers. Select the answer choice containing the correct statement.
Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in
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
The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.
The per diem reimbursement method will require Gladspell to pay Ellysium a
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
Health plans often negotiate compensation arrangements that transfer some or all of the financial risk associated with delivering healthcare services to network providers. The following statements are about these compensation arrangements. Select the answer choice containing the correct statement.
The Festival Health Plan is in the process of recruiting physicians for its provider network. Festival requires its network physicians to be board certified. The following individuals are provider applicants whose qualifications are being considered:
Applicant 1 has completed his surgical residency, and he recently passed a qualifying examination in his field.
Applicant 2 has completed her residency in dermatology, and she is scheduled to take qualifying examinations in the next Six months.
Applicant 3 completed his residency in pediatric medicine six years ago, but he has not yet passed a qualifying examination in his field.
With regard to these applicants, it can correctly be stated that only
