BCACP Ambulatory Practice Business Models 3 — Questions and Answers
Question 1: Which term describes a payment model where providers receive a fixed payment per patient per month to cover all specified services, regardless of utilization?
- Fee-for-service
- Pay-for-performance
- Capitation (Correct answer)
- Bundled payment
Correct answer: Capitation
Capitation provides a fixed per-member per-month payment, incentivizing providers to deliver preventive care and reduce unnecessary utilization.
Question 2: An ambulatory care pharmacist is proposing a diabetes management program. Which financial document projects the expected revenues and expenses over the first 3 years?
- Balance sheet
- Pro forma income statement (Correct answer)
- Break-even analysis worksheet
- Cash flow from operations statement
Correct answer: Pro forma income statement
A pro forma income statement projects anticipated revenues and expenses over a future period to estimate profitability of a proposed program.
Question 3: Under which model do pharmacists share in the savings achieved when total cost of care falls below a benchmark, while also being accountable for quality metrics?
- Medicare Advantage plan
- Accountable Care Organization (ACO) (Correct answer)
- Independent pharmacy network
- Pharmacy Benefit Manager contract
Correct answer: Accountable Care Organization (ACO)
ACOs allow providers including pharmacists to share in savings generated by coordinating care and reducing costs below a pre-set benchmark.
Question 4: A hospital-based outpatient pharmacy clinic loses money on a per-encounter basis but the hospital retains the service. This is MOST likely because:
- The pharmacy is required to operate under state law
- The service generates downstream revenue through reduced readmissions and increased admissions (Correct answer)
- The pharmacy has a contractual obligation with the PBM
- The service is funded entirely by a federal grant
Correct answer: The service generates downstream revenue through reduced readmissions and increased admissions
Hospital systems often subsidize ambulatory pharmacy services because they reduce costly readmissions and attract patients whose inpatient care generates significant revenue.
Question 5: Which CPT code category is MOST commonly used to bill for Medication Therapy Management Comprehensive Medication Review (CMR) services?
- Evaluation and Management (E&M) codes 99201-99215
- MTM-specific CPT codes 99605-99607 (Correct answer)
- Transitional care management codes 99495-99496
- Chronic care management codes 99490-99491
Correct answer: MTM-specific CPT codes 99605-99607
CPT codes 99605-99607 are specifically designated for billing pharmacist-provided MTM services including the CMR.
Question 6: In a value-based contract, a pharmacy service is penalized if its diabetes patient population's average HbA1c remains above 9%. This is an example of:
- Capitated reimbursement adjustment
- Pay-for-performance quality withhold (Correct answer)
- Fee-for-service clawback provision
- Prospective payment system penalty
Correct answer: Pay-for-performance quality withhold
Pay-for-performance contracts include financial incentives or penalties tied to achievement of specific quality benchmarks.
Question 7: A pharmacist starting an independent specialty medication management clinic should FIRST assess:
- Software vendors for electronic health records
- Market need, reimbursement landscape, and regulatory requirements (Correct answer)
- Staffing ratios and technician certification requirements
- Supply chain partnerships with specialty pharmacies
Correct answer: Market need, reimbursement landscape, and regulatory requirements
A viable business begins with a needs assessment that evaluates market demand, available reimbursement mechanisms, and the legal environment.
BCACP Ambulatory Practice Business Models 3
Which term describes a payment model where providers receive a fixed payment per patient per month to cover all specified services, regardless of utilization?