A Review Of Exact AHM-510 Vce

NEW QUESTION 1
In the paragraph below, a statement contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the statement. Then select the answer choice containing the two terms that you have chosen.
One type of acquisition is called a stock purchase. In a typical stock purchase, a company acquires (51% / 100%) of the voting shares of another company's stock, thereby making the acquired company a subsidiary. The (acquired / acquiring) company holds all of the assets and liabilities of the acquired company.

• A. 51% / acquired
• B. 51% / acquiring
• C. 100% / acquired
• D. 100% / acquiring

Answer: C

NEW QUESTION 2
The following situations illustrate per se violations of federal antitrust laws:
Situation A - Two groups of providers agreed among themselves that each provider will do business with health plans only on a fee-for-service basis.
Situation B - In order to avoid competing with each other, two independent, competing physicianhospital organizations (PHOs) divide the geographic areas in which they will market their services.
From the following answer choices, select the response that correctly identifies the types of per se violations illustrated by these situations.

• A. Situation A: price fixing; Situation B: horizontal division of markets
• B. Situation A: price fixing; Situation B: tying arrangement
• C. Situation A: horizontal group boycott; Situation B: horizontal division of markets
• D. Situation A: horizontal group boycott; Situation B: tying arrangement

Answer: A

NEW QUESTION 3
Arthur Dace, a plan member of the Bloom Health Plan, tried repeatedly over an extended period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr. Dace informally surveyed other Bloom plan members and found that many people were experiencing similar problems getting an appointment with this particular provider. Mr. Dace threatened to take legal action against Bloom, alleging that the health plan had deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making it difficult for patients to make appointments with Dr. Pyle.
Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR)
method that is quicker and less expensive than litigation. Under this ADR method, both Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who issued a decision that Bloom's utilization management practices in this case did not constitute a form of abuse. The panel's decision is legally binding on both parties.
This information indicates that Bloom resolved its dispute with Mr. Dace by using an ADR method known as:

• A. Corporate risk management
• B. An ombudsman program
• C. An ethics committee
• D. Arbitration

Answer: D

NEW QUESTION 4
The Department of Health and Human Services (HHS) has delegated its responsibility for development and oversight of regulations under the Health Insurance Portability and Accountability Act (HIPAA) to an office within the Centers for Medicaid & Medicare Services (CMS). The CMS office that is responsible for enforcing the federal requirements of HIPAA is the

• A. Center for Health Plans and Providers (CHPPs)
• B. Center for Medicaid and State Operations
• C. Center for Beneficiary Services
• D. Center for Managed Care

Answer: B

NEW QUESTION 5
Health maintenance organizations (HMOs) seeking federal qualification under the HMO Act of 1973 and its amendments must meet requirements in four basic operational areas. One operational requirement for qualification is that an HMO must

• A. Ensure that at least 1/3 of its policy-making body is comprised of HMO members
• B. Ensure that there is adequate representation of underserved communities on its policy-making body
• C. Have an ongoing quality assurance program that meets the requirements of the Centers for Medicaid & Medicare Services (CMS), stresses health outcomes, and provides for review by health professionals
• D. Test, safeguard, and promote quality of care by following detailed programmatic techniques that are explained in CMS's Federally Qualified HMO (FQHMO) Manual

Answer: C

NEW QUESTION 6
In examining accountability in the current managed care environment, one is likely to find that combinations of various models of accountability are in operation. Under one model of accountability, the primary mechanisms for accountability are the mechanisms of the marketplace- failure to meet standards will result in a loss of demand for services. By definition, this model of accountability is called the

• A. Professional model of accountability
• B. Political model of accountability
• C. Due diligence model of accountability
• D. Economic model of accountability

Answer: D

NEW QUESTION 7
The Nonprofit Institutions Act allows the Neighbor Hospital, a not-for-profit hospital, to purchase at a discount drugs for its 'own use'. Consider whether the following sales of drugs were not for Neighbor's own use and therefore were subject to antitrust enforcement:
Elijah Jamison, a former patient of Neighbor, renewed a prescription that was originally dispensed when he was discharged from Neighbor.
Neighbor filled a prescription for Camille Raynaud, who has no connection to Neighbor other than that her prescribing physician is located in a nearby physician's office building.
Neighbor filled a prescription for Nigel Dixon, who is a friend of a Neighbor medical staff member. With respect to the United States Supreme Court's definition of 'own use,' the drug sales that were not for Neighbor's own use were the sales that Neighbor made to

• A. M
• B. Jamison, M
• C. Raynaud, and M
• D. Dixon
• E. M
• F. Jamison and M
• G. Raynaud only
• H. M
• I. Dixon only
• J. None of these individuals

Answer: A

NEW QUESTION 8
Greenpath Health Services, Inc., an HMO, recently terminated some providers from its network in
response to the changing enrollment and geographic needs of the plan. A provision in Greenpath's contracts with its healthcare providers states that Greenpath can terminate the contract at any
time, without providing any reason for the termination, by giving the other party a specified period of notice.
The state in which Greenpath operates has an HMO statute that is patterned on the NAIC HMO Model Act, which requires Greenpath to notify enrollees of any material change in its provider network. As required by the HMO Model Act, the state insurance department is conducting an examination of Greenpath's operations. The scope of the on-site examination covers all aspects of Greenpath's market conduct operations, including its compliance with regulatory requirements. From the following answer choices, select the response that identifies the type of market conduct examination that is being performed on Greenpath and the frequency with which the HMO Model Act requires state insurance departments to conduct an examination of an HMO's operations.

• A. Type of examination: comprehensive; Required frequency: annually
• B. Type of examination: comprehensive; Required frequency: at least every three years
• C. Type of examination: target; Required frequency: annually
• D. Type of examination: target; Required frequency: at least every three years

Answer: B

NEW QUESTION 9
The following answer choices describe various approaches that a health plan can take to voice its opinions on legislation. Select the answer choice that best describes a health plan's use of grassroots lobbying.

• A. The Delancey Health Plan is launching a media campaign in an effort to persuade the public that proposed health care legislation will increase the cost of healthcare.
• B. The Stellar Health Plan is using direct mail and telephone calls to encourage people who support a patient rights bill to contact key legislators and voice their support for the bill.
• C. The Bestway Health Plan is encouraging its employees to contribute to a political action committee (PAC) that is funding the political campaign of a pro-health plan candidate.
• D. A representative of the Palmer Health Plan is attending a one-on-one meeting with a legislator to present Palmer's position on pending managed care legislation.

Answer: B

NEW QUESTION 10
SoundCare Health Services, a health plan, recently conducted a situation analysis. One step in this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activity provided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detecting violations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.
With respect to the Federal Sentencing Guidelines, actions that SoundCare should take in developing its compliance program include

• A. Creating a system through which employees and other agents can report suspected misconduct without fear of retribution
• B. Holding management accountable for the misconduct of their subordinates
• C. Assigning a high-level member of management to the position of compliance coordinator or administrator
• D. All of the above

Answer: D

NEW QUESTION 11
Antitrust laws can affect the formation, merger activities, or acquisition initiatives of a health plan. In the United States, the two federal agencies that have the primary responsibility for enforcing antitrust laws are the

• A. Internal Revenue Service (IRS) and the Department of Justice (DOJ)
• B. Office of Inspector General (OIG) and the Department of Defense (DOD)
• C. Federal Trade Commission (FTC) and the Department of Labor (DOL)
• D. Federal Trade Commission (FTC) and the Department of Justice (DOJ)

Answer: D

NEW QUESTION 12
SoundCare Health Services, an MCO, recently conducted a situation analysis. One step in this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activity
provided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detecting violations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.
By definition, the activity that SoundCare conducted when it examined its strengths, weaknesses, and capabilities is known as

• A. An environmental analysis
• B. An internal assessment
• C. An environmental forecast
• D. A community analysis

Answer: B

NEW QUESTION 13
The following statements are about the Federal Employees Health Benefits Program (FEHBP), which is administered by the Office of Personnel Management (OPM). Three of the statements are true and one statement is false. Select the answer choice that contains the FALSE statement.

• A. For every plan in the FEHBP, OPM annually determines the lowest premium that is actuarially sound and then negotiates with each plan to establish that premium rate.
• B. Once a health plan has submitted its rate proposals for a contract year to the OPM, it cannot adjust its premium rate for any reason.
• C. To cover its administrative costs, OPM sets aside 1% of all FEHBP premiums.
• D. Each spring, OPM sends all plan providers its call letter, a document that specifies the kinds of benefits that must be available to plan participants and cost goals and procedural changes that the plans need to adopt.

Answer: A

NEW QUESTION 14
A federal law that significantly affects health plans is the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In order to comply with HIPAA provisions, issuers offering group health coverage generally must.

• A. Renew group health policies in both small and large group markets, regardless of the health status of any group member
• B. Provide a plan member with a certificate of creditable coverage at the time the member enrolls in the group plan
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: B

NEW QUESTION 15
One provision of the Mental Health Parity Act of 1996 (MHPA) is that the MHPA prohibits group health plans from

• A. Setting a cap for a group member's lifetime medical health benefits that is higher than the cap for the member's lifetime mental health benefits
• B. Imposing limits on the number of days or visits for mental health treatment
• C. Charging deductibles for mental health benefits that are higher than the deductibles for medical benefits
• D. Imposing annual limits on the number of outpatient visits and inpatient hospital stays for mental health services

Answer: A

NEW QUESTION 16
Determine whether the following statement is true or false:
Failing to adopt and implement standards for the prompt investigation and settlement of claims is an example of an activity that would be considered an improper claims practice according to the NAIC Model Unfair Claims Settlement Practices Act.

• A. True
• B. False

Answer: A

NEW QUESTION 17
Health plans should monitor changes in the environment and emerging trends, because changes
in society will affect the managed care industry. One true statement regarding recent changes in the environment in which health plans operate is that

• A. Women as a group receive more healthcare and interact more often with health plans than do men over the course of a lifetime
• B. The focus of healthcare during the past decade has shifted away from outpatient care to inpatient hospital treatment
• C. The uninsured population in the United States has been decreasing in recent years
• D. The decline in overall inflation in the 1990s failed to slow the growth in healthcare inflation

Answer: A

NEW QUESTION 18
The following statements are about market conduct examinations of health plans. Select the answer choice that contains the correct statement.

• A. Multistate examinations are not appropriate for financial examinations, because regulatory requirements concerning a health plan's financial condition tend to vary from state to state.
• B. Market conduct examinations of a health plan's advertising and sales materials include comparing the advertising materials to the policies they advertise.
• C. Once an examination report is provided to the state insurance department, a health plan is not given an opportunity to present a formal objection to the report.
• D. In imposing sanctions on health plans, state insurance departments are required to follow federal sentencing guidelines.

Answer: B

NEW QUESTION 19
There are several exceptions to the Ethics in Patient Referrals Act and its amendments (the Stark laws), which prohibit a physician from referring Medicare or Medicaid patients for certain designated services or supplies provided by entities in which the physician has a financial interest. Consider whether the situations described below qualify as exceptions to the Stark laws:
Situation A: Dr. Wong is a physician in the Marvel Health Plan's provider network and has a financial relationship with Marvel arising from the health plan's compensation for his services. Marvel is not a prepaid health plan.
Situation B: Dr. Ryder is a physician in the provider network of the Glen Health Plan, which is not a prepaid health plan. In situations of medical necessity, Dr. Ryder refers Glen patients to a physical therapy clinic that leases office space from him.
Situation C: Dr. Yost has a compensation arrangement with a health plan for providing health services under the Medicare+Choice program.
An arrangement that is exempt from the Stark laws is described in

• A. All of these situations
• B. Situations A and C only
• C. Situation B only
• D. Situation C only

Answer: D

NEW QUESTION 20
From the following answer choices, choose the term that best corresponds to this description. The
SureQual Group is a group of practicing physicians and other healthcare professionals paid by the federal government to review services ordered or furnished by other practitioners in the same medical fields for the purpose of determining whether medical services provided were reasonable and necessary, and to monitor the quality of care given to Medicare patients.

• A. Health insuring organization (HIO)
• B. Independent practice association (IPA)
• C. Physician practice management (PPM) company
• D. Peer review organization (PRO)

Answer: D

NEW QUESTION 21
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