AHM-510 Governance, Legal Issues, Medicare & Medicaid Practice Questions

Congress enacted three clauses relating to the preemptive effect of the Employee Retirement Income Security Act of 1974 (ERISA). One of these clauses preserves from ERISA preemption any state law that regulates insurance, banking, or securities, with the exception of the exemption for self-funded employee benefit plans. This clause is called the: A.Savings clauseB.Preemption clauseC.Deemer clauseD.De novo clause

Any willing provider laws have their share of proponents and opponents. Arguments commonly made in opposition to any willing provider laws include: A.That such laws reduce the number of providers in a health plan's networkB.That such laws limit consumer choice to coverage options that are more costly than network based plansC.That such laws encourage providers to offer discounts in exchange for patient volumeD.All of the above

From the following answer choices, choose the term that best corresponds to this description. Barrington Health Services, Inc. contracts with a state Medicaid agency as a fiscal intermediary. Barrington does not provide medical services, but contracts with medical providers on behalf of the state Medicaid agency. A.Health insuring organization (HIO)B.Independent practice association (IPA)C.Physician practice management (PPM) companyD.Peer review organization (PRO)

The Good & Well Pharmacy, a Medicaid provider of outpatient drugs, is subject to the prospective drug utilization review (DUR) mandates of the Omnibus Budget Reconciliation Act of 1990 (OBRA '90). One component of prospective DUR is screening. In this context, when Good & Well is involved in the process of screening, the pharmacy is: A.Updating a formulary to represent the current clinical judgment of providers and experts in the diagnosis and treatment of diseaseB.Reviewing patient profiles for the purpose of identifying potential problemsC.Consulting directly with prescribers and patients in the planning of drug therapyD.Denying coverage for the off-label use of approved drugs