Top Tips Of Replace AHM-530 Testing Material

NEW QUESTION 1

One important aspect of network management is profiling, or provider profiling. Profiling is most often used to

• A. measure the overall performance of providers who are already participants in the network
• B. assess a provider’s overall satisfaction with a plan’s service protocols and other operational areas
• C. verify a prospective provider’s professional licenses, certifications, and training
• D. familiarize a provider with a plan’s procedures for authorizations and referrals

Answer: A

NEW QUESTION 2

The Pine Health Plan has incorporated pharmacy benefits management into its operations to form a unified benefit. Potential advantages that Pine can receive from this action include:

• A. the fact that unified benefits improve the quality of patient care and the value of pharmacy services to Pine's plan members
• B. the fact that control over the formulary and network contracting can give Pine control over patient access to prescription drugs and to pharmacies
• C. the fact that managing pharmacy benefits in-house gives Pine a better chance to meet customer needs by integrating pharmacy services into the plan's total benefits package
• D. all of the above

Answer: D

NEW QUESTION 3

A provider contract describes the responsibilities of each party to the contract. These responsibilities can be divided into provider responsibilities, health plan responsibilities, and mutual obligations. Mutual obligations typically include

• A. provisions for marketing the plan’s product
• B. payment arrangements between the plan and the provider
• C. verification of the plan’s eligibility to do business
• D. management of the contents of members’ medical records

Answer: B

NEW QUESTION 4

The NPDB specifies the entities that are eligible to request information from the data bank, as well as the conditions under which requests are allowed. In general, entities that are eligible to request information from the NPDB include

• A. medical malpractice insurers and the general public
• B. medical malpractice insurers and professional societies that are screening applicants for membership
• C. the general public and state licensing boards
• D. state licensing boards and professional societies that are screening applicants for membership

Answer: D

NEW QUESTION 5

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.
A formulary lists the drugs and treatment protocols that are considered to be the preferred
therapy for a given managed population. The Fairfax Health Plan uses the type of formulary which covers drugs that are on its preferred list as well as drugs that are not on its preferred list. This information indicates that Fairfax uses the (closed / open) formulary method. In using the formulary approach to pharmacy benefits management, Fairfax most likely experiences (higher / lower) costs for its members’ prescription drugs than it would if it did not use a formulary.

• A. closed / higher
• B. closed / lower
• C. open / higher
• D. open / lower

Answer: D

NEW QUESTION 6

The following statements describe two types of HMOs:
The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.
The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.
Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.
Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:
The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents
per tablet for this drug.
The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.
From the following answer choices, select the response that best identifies Elm and Treble:

• A. Elm: open access (OA) HMO Treble: direct access HMO
• B. Elm: open access (OA) HMO Treble: gatekeeper HMO
• C. Elm: direct access HMO Treble: open access (OA) HMO
• D. Elm: direct access HMO Treble: gatekeeper HMO

Answer: C

NEW QUESTION 7

For this question, if answer choices (A) through C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Understanding the level of health plan penetration in a particular market can help a health plan determine which products are most appropriate for that market. Indicators of a mature health plan market include

• A. Areduction in the rate of growth in health plan premium levels
• B. Areduction in the level of outcomes management and improvement
• C. An increase in the rate of inpatient hospital utilization
• D. All of the above

Answer: A

NEW QUESTION 8

The provider contract that Dr. Lorena Chau has with the Fiesta Health Plan includes an evergreen clause. The purpose of this clause is to:

• A. Allow Fiesta to change or amend the contract without D
• B. Chau's approval as long as the modifications are made in order to comply with new legal and regulatory requirements
• C. Prohibit D
• D. Chau from encouraging her patients to switch from Fiesta to another health plan
• E. Prohibit D
• F. Chau from encouraging her patients to switch from Fiesta to another health plan
• G. Assure that D
• H. Chau provides Fiesta members with healthcare services in a timely manner appropriate to the member's medical condition

Answer: C

NEW QUESTION 9

The following statements are about managed dental care. Three of these statements are true, and one is false. Select the answer choice containing the FALSE statement.

• A. Managed dental care is federally regulated.
• B. Dental HMOs typically need very few healthcare facilities because almost all dental services are delivered in an ambulatory care setting.
• C. Currently, there are no nationally recognized standards for quality in managed dental care.
• D. Processes for selecting dental care providers vary greatly according to state regulationson managed dental care networks and the health plan’s standards.

Answer: A

NEW QUESTION 10

The Octagon Health Plan includes a typical indemnification clause in its provider contracts. The purpose of this clause is to require Octagon’s network providers to

• A. Agree not to sue or file claims against an Octagon plan member for covered services
• B. Reimburse Octagon for costs, expenses, and liabilities incurred by the health plan as a result of a provider’s actions
• C. Maintain the confidentiality of the health plan’s proprietary information
• D. Agree to accept Octagon’s payment as payment in full and not to bill members for anything other than contracted copayments, coinsurance, or deductibles

Answer: B

NEW QUESTION 11

One reimbursement method that health plans can use for hospitals is the ambulatory payment classifications (APCs) method. APCs bear a resemblance to the diagnosis-related groups (DRGs) method of reimbursement. However, when comparing APCs and DRGs, one of the primary differences between the two methods is that only the APC method

• A. is typically used for outpatient care
• B. assigns a single code for treatment
• C. applies to treatment received during an entire hospital stay
• D. is considered to be a retrospective payment system

Answer: A

NEW QUESTION 12

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan member for covered services is known as:

• A. Atermination with cause clause
• B. Ahold-harmless clause
• C. An indemnification clause
• D. Acorrective action clause

Answer: B

NEW QUESTION 13

The following statements are about the responsibilities that providers are expected to assume under most provider contracts with health plans. Select the answer choice containing the correct statement.

• A. All health plans now include in their provider contracts a statement that explicitly places responsibility for the medical care of plan members on the health plan rather than on the provider.
• B. According to the wording of most provider contracts, the responsibility of providers to deliver medical services to a plan member is not contingent upon the provider’s receipt of information regarding the member’s eligibility for these services.
• C. Most health plans include in their provider contracts a clause which requires providers to maintain open communication with plan members regarding appropriate treatment plans, even if the services are not covered by the member’s health plan.
• D. Most provider contracts require participating providers to discuss health plan payment arrangements with patients who are covered by the plan.

Answer: C

NEW QUESTION 14

The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
Qualitative measures that Azure could use to assess provider performance include an evaluation of how

• A. Quickly the provider responds to plan members’ inquiries
• B. Effectively the provider communicates with plan members
• C. Often the provider refers plan members for ancillary services
• D. Many plan members visit the provider per month

Answer: C

NEW QUESTION 15

The provider contract between the Regal Health Plan and Dr. Caroline Quill contains a type of termination clause known as termination without cause. One true statement about this clause is that it

• A. Requires Regal to send a report to the appropriate accrediting agency if the health plan terminates D
• B. Quill’s contract without cause
• C. Requires that Regal must base its decision to terminate D
• D. Quill’s contract on clinical criteria only
• E. Allows either Regal or D
• F. Quill to terminate the contract at any time, without any obligation to provide a reason for the termination or to offer an appeals process
• G. Allows Regal to terminate D
• H. Quill’s contract at the time of contract renewal only, without any obligation to provide a reason for the termination or to offer an appeals process

Answer: C

NEW QUESTION 16

State Medicaid agencies can contract with health plans through open contracting or selective contracting. One advantage of selective contracting is that it

• A. Allows enrollees to choose from among a greater variety of health plans
• B. Reduces the competition among health plans
• C. Increases the ability of new, local plans to participate in Medicaid programs
• D. Encourages the development of products that offer enhanced benefits and more effective approaches to health plans

Answer: D

NEW QUESTION 17

In order to evaluate and manage the performance of individual providers in its provider network, the Quorum Health Plan implemented a program that focuses on identifying the best and worst outcomes and utilization patterns of its providers. This program is also designed to develop and implement strategies such as treatment protocols and practice guidelines to improve the performance of Quorum's providers. This information indicates that Quorum implemented a program known as:

• A. An integrated delivery system (IDS)
• B. A coordinated care program
• C. Ostensible agency
• D. Continuous quality improvement (CQI)

Answer: D

NEW QUESTION 18

From the following answer choices, choose the type of clause or provision described in this situation.
The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.

• A. Cure provision
• B. Hold-harmless provision
• C. Evergreen clause
• D. Exculpation clause

Answer: C

NEW QUESTION 19
......