Users of the Fulcrum Health Plan financial information include:
The independent auditors who review Fulcrum's financial statements
Fulcrum's controller (comptroller)
Fulcrum's plan members
The providers that deliver healthcare services to Fulcrum plan members
Fulcrum's competitors
Of these users, the ones that most likely can correctly be classified as external users with a direct
financial interest in Fulcrum are the
D
The Eclipse Health Plan is a not-for-profit health plan that qualifies under the Internal Revenue Code
for tax-exempt status. This information indicates that Eclipse
B
The Challenger Group is a type of management services organization (MSO) that purchases the
assets of physician practices, provides practice management and administrative support services to
participating providers, and offers physicians a long-term contract and an equity position in
Challenger. This information indicates that Challenger is a type of health plan
D
A key factor that distinguishes the various types of health plans is the type and amount of risk that a
health plan assumes with respect to the delivery and financing of healthcare benefits. An example of
a type of health plan that typically assumes the financial risk of delivering and financing healthcare
benefits is a
C
The following statements are about pure risk and speculative risk—two kinds of risk that both
businesses and individuals experience. Select the answer choice containing the correct statement.
A
The following paragraph contains an incomplete statement. Select the answer choice containing the
term that correctly completes the statement. Health plans face four contingency risks (C-risks): asset
risk (C-1), pricing risk (C-2), interest-rate risk (C-3), and general management risk (C-4). Of these
risks, ________________ is typically the most important risk that health plans face. This is true
because a sizable portion of the total expenses and liabilities faced by a health plan come from
contractual obligations to pay for future medical costs, and the exact amount of these costs is not
known when the healthcare coverage is priced.
B
The Health Maintenance Organization (HMO) Model Act, developed by the National Association of
Insurance Commissioners (NAIC), represents one approach to developing solvency standards. One
drawback to this type of solvency regulation is that it
C
The NAIC has developed a risk-based capital (RBC) formula for all health plans that accept risk. One
true statement about the RBC formula for health plans is that it
A
Provider reimbursement methods that transfer some utilization risk from a health plan to providers
affect the health plan's RBC formul
a. A health plan's use of these reimbursement methods is likely to result in
C
Three general strategies that health plans use for controlling types of risk are risk avoidance, risk
transfer, and risk acceptance. The following statements are about these strategies. Three of these
statements are true, and one statement is false. Select the answer choice containing the FALSE
statement.
B
Under the doctrine of corporate negligence, a health plan and its physician administrators may be
held directly liable to patients or providers for failing to investigate adequately the competence of
healthcare providers whom it employs or with whom it contracts, particularly where the health plan
actually provides healthcare services or restricts the patient's/enrollee's choice of physician.
A
The Eagle health plan wants to limit the possibility that it will be held vicariously liable for the
negligent acts of providers. Dr. Michael Chan is a member of an independent practice association
(IPA) that has contracted with Eagle. One step that Eagle could take in order to limit its exposure
under the theory of vicarious liability is to
D
Rasheed Azari, the risk manager for the Tower health plan, is attempting to work with providers in
the organization in order to reduce the providers' exposure related to utilization review. Mr. Azari is
considering advising the providers to take the following actions:
1-Allow Tower's utilization management decisions to override a physician's independent medical
judgment
2-Support the development of a system that can quickly render a second opinion in case of
disagreement surrounding clinical judgment
3-Inform a patient of any issues that are being disputed relative to a physician's recommended
treatment plan and Tower's coverage decision
Of these possible actions, the ones that are likely to reduce physicians' exposures related to
utilization review include actions
D
The following statements are about risk management in health plans. Select the answer choice
containing the correct response.
D
Several federal agencies establish rules and requirements that affect health plans. One of these
agencies is the Department of Labor (DOL), which is primarily responsible for _________.
C