Question 1

One difference between a fee-for-service (FFS) reimbursement arrangement and capitation is that the FFS arrangement:

AIs a prospective payment system, whereas capitation is a retrospective payment system

BHas a potential to induce providers to underutilize medical resources, whereas capitation does not have this potential disadvantage

CBases the amount of reimbursement on the actual medical services delivered, whereas reimbursement under capitation is independent of the actual volume and cost of services provided

DIs most often used by health plans to reimburse healthcare facilities, whereas capitation is most often used by health plans to reimburse specialty care providers

Answer : C

Question 2

Partial capitation is one common approach to capitation. One typical characteristic of partial capitation is that it:

AIncludes only primary care services

BCovers such services as immunizations and laboratory tests

CCan be used only if the provider's panel size is less than 50 providers

DCovers such services as cardiology and orthopedics

Answer : A

Question 3

Under the compensation arrangement that the Falcon Health Plan has with some of its providers, Falcon holds back 10% of the negotiated payments to these providers in order to offset or pay for any claims that exceed the budgeted costs for referral or hospital services. If the providers keep costs within the budgeted amount, Falcon distributes to them the entire amount of money held back. This way of motivating providers to control costs while providing high-quality, appropriate care is known as a:

ARisk pool arrangement

BWithhold arrangement

CCost-shifting arrangement

DBonus pool arrangement

Answer : B

Question 4

A provider group purchased from an insurer individual stop-loss coverage for primary and specialty care services with an $8,000 attachment point and 10% coinsurance. If the group's accrued cost for the primary and specialty care treatment of one patient is $10,000, then the amount that the insurer would be responsible for reimbursing the provider group for these costs is:

A$200

B$1,000

C$1,800

D$9,000

Answer : C

Question 5

The Foxfire Health Plan, which has 20,000 members, contracts with dermatologists on a contact capitation basis. The contact capitation arrangement has the following features:

Foxfire distributes the money in the contact capitation fund once each quarter and the distribution is based on the point totals accumulated by each dermatologist.

Foxfire's per member per month (PMPM) capitation for dermatology services is $1.

The dermatologist receives 1 point for each new referral that is not classified as a complicated referral and 1.5 points for each new referral that is classified as complicated.

During the first quarter, Foxfire's PCPs made 450 referrals to dermatologists and 100 of these referrals were classified as complicated. One dermatologist, Dr. Shareef Rashad, received 42 of these referrals; 6 of his referrals were classified as complicated. Statements that can correctly be made about Foxfire's contact capitation arrangement include:

Athat the value of each referral point for the first quarter was $120

Bthat the value of Foxfire's contact capitation fund for dermatologists for the first quarter was $20,000

Cthat the payment that Foxfire owed Dr. Rashad for the first quarter was $6,120

Dall of the above