Improved AHM-250 Questions 2021

NEW QUESTION 1

In order to measure the expenses of institutional utilization, Holt Healthcare Group uses the standard formula to calculate hospital bed days per 1,000 plan members per year. On October 23, Holt used the following information to calculate the bed days per

• A. 278
• B. 397
• C. 403
• D. 920

Answer: B

NEW QUESTION 2

One ethical principle in managed care is the principle of justice/equity, which specifically holds that MCOs and their providers have a duty to

• A. treat each member in a manner that respects his or her own goals and values
• B. allocate resources in a way that fairly distributes benefits and burdens among the members
• C. present information honestly to their members and to honor commitments to their members
• D. make sure they do not harm their members

Answer: B

NEW QUESTION 3

The following statements describe individuals who are applying for individual health insurance coverage:
Six months ago, Wilbur Lee lost his health insurance coverage due to a reduction in work hours and has exhausted his coverage under COBRA. Mr. Lee has

• A. both M
• B. Lee and M
• C. Beeker
• D. M
• E. Lee only
• F. M
• G. Beeker only
• H. neither M
• I. Lee nor M
• J. Beeker

Answer: A

NEW QUESTION 4

As part of its quality management program, the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. When Lyric concludes that its competitor's practices or services are better than its own, Lyric im

• A. Benchmarking.
• B. Standard of care.
• C. An adverse event.
• D. Case-mix adjustment.

Answer: A

NEW QUESTION 5

The parties to the contractual relationship that provides Castle's group health coverage to Knoll employees are

• A. Castle and Knoll only
• B. Knoll and all covered Knoll employees only
• C. Castle, Knoll, and all covered Knoll employees
• D. Castle and all covered Knoll employees only

Answer: A

NEW QUESTION 6

Patrick Flaherty's employer has contracted to receive healthcare for its employees from the Abundant Healthcare System. Mr. Flaherty visits his primary care physician (PCP), who sends him to have some blood tests. The PCP then refers Mr. Flaherty to a special

• A. an integrated delivery system (IDS)
• B. a Management Services Organization (MSO)
• C. a Physician Practice Management (PPM) company
• D. a physician-hospital organization (PHO)

Answer: A

NEW QUESTION 7

A health plan may use one of several types of community rating methods to set premiums for a health plan. The following statements are about community rating. Select the answer choice containing the correct statement.

• A. Standard (pure) community rating is typically used for large groups because it is the most competitive rating method for large groups.
• B. Under standard (pure) community rating, a health plan charges all employers or other group sponsors the same dollar amount for a given level of medical benefits or health plan, without adjusting for factors such as age, gender, or experience.
• C. In using the adjusted community rating (ACR) method, a health plan must consider the actual experience of a group in developing premium rates for that group.
• D. The Centers for Medicare and Medicaid Services (CMS) prohibits health plans that assume Medicare risk from using the adjusted community rating (ACR) me

Answer: B

NEW QUESTION 8

The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential

• A. $140
• B. $170
• C. $180
• D. $210

Answer: B

NEW QUESTION 9

From the following choices, choose the definition that best matches the term Screening

• A. A technique used to educate plan members on how to distinguish between minor problems and serious conditions and effectively treat minor problems themselves
• B. A technique used to determine if a health condition is present even if a member has not experienced symptoms of the problem
• C. A technique in which information about a plan member's health status, personal and family health history, and health-related behaviors is used to predict the member's likelihood of experiencing specific illnesses or injuries
• D. A technique used to evaluate the medical necessity, appropriateness, and cost- effectiveness of healthcare services for a given patient

Answer: B

NEW QUESTION 10

Parul Gupta has been covered by a group health plan for eighteen months. For the past four months, she has been undergoing treatment for diabetes. Last week, Ms. Gupta began a new job and immediately enrolled in her new company's group health plan, which

• A. can exclude coverage for treatment of M
• B. Gupta's diabetes for one year, because she did not have at least two years of creditable coverage under her previous health plan
• C. cannot exclude M
• D. Gupta's diabetes as a pre-existing condition, because the one-year pre-existing condition provision is offset by at least one year of continuous coverage under her previous health plan
• E. can exclude coverage for treatment of M
• F. Gupta's diabetes for one year, because HIPAA does not impact a group health plan's pre-existing condition provision
• G. can exclude coverage for treatment of M
• H. Gupta's diabetes for four months, because that is the length of time she received treatment for this medical condition prior to her enrollment in the new health plan

Answer: B

NEW QUESTION 11

In most cases, medical errors are caused by breakdowns in the healthcare system rather than by provider mistakes.

• A. True
• B. False

Answer: A

NEW QUESTION 12

In 1999, the United States Congress passed the Financial Services Modernization Act, which is referred to as the Gramm-Leach-Bliley (GLB) Act. The following statement(s) can correctly be made about this act:

• A. The GLB Act allows convergence among the transaction
• B. A only
• C. Both A and B
• D. B only
• E. Neither A nor B

Answer: B

NEW QUESTION 13

System classifies hundreds of hospital services based on a number of criteria, such as primary and secondary diagnosis, surgical procedures, age, gender, and the presence of complications.

• A. Carve-out
• B. DRG
• C. Global capitation
• D. Partial capitation

Answer: B

NEW QUESTION 14

When determining the rates it will charge a small group, the Eagle HMO, a federally qualified HMO, divides its members into classes or groups based on demographic factors such as geography, family composition, and age. Eagle then charges all members of a

• A. Retrospective experienced rating.
• B. Adjusted community rating (ACR).
• C. Pure community rating.
• D. Standard community rating.

Answer: B

NEW QUESTION 15

The Titanium Health Plan and a third-party administrator (TPA) have entered into a TPA agreement with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. One of the TPA's

• A. Hold all funds it receives on behalf of Titanium in trust.
• B. Assume full responsibility for ensuring that the health plan is administered properly
• C. Obtain from the federal government a certificate of authority designating the organization as a TPA.
• D. Assume full responsibility for determining the claim payment procedures for the plan

Answer: A

NEW QUESTION 16

The measures used to evaluate healthcare quality are generally divided into three categories: process, structure and outcomes. An example of a process measure that can be used to evaluate an MCO's performance is the

• A. percentage of board certified physicians within the MCO's network
• B. number of hospital admissions for plan members with certain medical conditions
• C. number of plan members contracting an infection in the hospital
• D. percentage of adult plan members who receive regular medical checkups

Answer: D

NEW QUESTION 17

Ronald Canton is a member of the Omega MCO. He receives his nonemergency medical care from Dr. Kristen High, an internist. When Mr. Canton needed to visit a cardiologist about his irregular heartbeat, he first had to obtain a referral from Dr. High to see

• A. D
• B. High serves as the coordinator of care for the medical services that M
• C. Canton receives.
• D. Omega's network of providers includes D
• E. High, but not D
• F. Miller.
• G. Omega's system allows its members open access to all of Omega's participating providers.
• H. Omega used a financing arrangement known as a relative value scale (RVS) to compensate D
• I. Miller.

Answer: A

NEW QUESTION 18

The feature that formed the foundation of Health Maintenance Act of 1973

• A. Federal Qualification Requirements
• B. Exemption from state laws
• C. All of the above

Answer: C

NEW QUESTION 19

By definition, the marketing process of defining a certain place or market niche for a product relative to competitors and their products and then using the marketing mix to attract certain market segments is known as

• A. branding
• B. positioning
• C. database marketing
• D. personal selling

Answer: B

NEW QUESTION 20

The Meadowcreek Group is an organization comprised of individual physicians and physicians in small group practices. Meadowcreek enters into contracts with health plans, and then Meadowcreek contracts separately with its physician members. In situations w

• A. a group practice without walls (GPWW)
• B. a messenger model
• C. an individual practice association (IPA)
• D. a Physician Practice Management (PPM) company

Answer: C

NEW QUESTION 21

The Polestar Company's sole business is the ownership of Polaris Medical Group, a health plan and subsidiary of Polestar. Some members of Polestar's board of directors hold positions with Polestar in addition to their positions on the board; the rest are

• A. Polestar's relationship to Polaris: partnership Type of board member: operations director
• B. Polestar's relationship to Polaris: partnership Type of board member: outside director
• C. Polestar's relationship to Polaris: holding company Type of board member: operations director
• D. Polestar's relationship to Polaris: holding company Type of board member: outside director

Answer: D

NEW QUESTION 22

When the Knoll Company purchased group health coverage from the Castle Health Maintenance Organization (HMO), the agreement between the two parties specified that the plan would be a typical fully funded plan. Because Knoll had been covered under a previous

• A. 230
• B. 270
• C. 220
• D. 180

Answer: C

NEW QUESTION 23

The following programs are part of the Alcove MCO's utilization management (UM) program:
✑ A telephone triage program
✑ Preventive care initiatives
✑ A shared decision-making program
✑ A self-care program
With regard to the UM programs, it is most likely cor

• A. self-care program is intended to complement physicians' services, rather than to supercede or eliminate these services
• B. telephone triage program is staffed by physicians only
• C. shared decision-making program is appropriate for virtually any medical condition
• D. preventive care initiatives include immunization programs but not health promotion programs

Answer: A

NEW QUESTION 24

By offering a comprehensive set of healthcare benefits to its members, an HMO ensures that its members obtain quality, cost-effective, and appropriate medical care. Ways that an HMO provides comprehensive care include

• A. coordinating care across a variety of benefits
• B. emphasizing preventive care by covering many preventive services either in full or with a small copayment
• C. offering its members access to wellness programs
• D. All of the above

Answer: D

NEW QUESTION 25

Primary care case managers (PCCMs) provide managed healthcare services to eligible Medicaid recipients. With regard to PCCMs, it is correct to say that

• A. PCCMs contract directly with the federal government to provide case management services to Medicaid recipients
• B. all Medicaid recipients who live in rural areas must be given a choice of at least four PCCMs
• C. Medicaid PCCM programs are exempt from the Health Care Financing Administration's (HCFA's) Quality Improvement System for Managed Care (QISMC) standards
• D. PCCMs typically receive a case management fee, rather than reimbursement for medical services on a FFS basis, for the services they provide to Medicaid recipients

Answer: C

NEW QUESTION 26

The following statement(s) can correctly be made about the characteristics of reports that should be provided to managers for use in managing a healthcare delivery system:

• A. Users typically need access to all the raw data used to generate reports
• B. Info
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: D

NEW QUESTION 27

In order to measure the expenses of institutional utilization, Holt Health care group uses standard formula to calculate hospital bed stays per 1000 plan members. On 26 November, Holt uses the following information to:
Calculate the bed days per 1000 members for the MTD Total gross hospital bed days in MTD = 500
Plan membership = 15000
Calculate Holt's number of bed days per 1000 members for the month to date, rounded to the nearest whole number.

• A. 468
• B. 365
• C. 920
• D. 500

Answer: A

NEW QUESTION 28
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