The Secret Of AHIP AHM-530 Answers

NEW QUESTION 1

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.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:

• A. D
• B. Enberg's young patients receive appropriate immunizations at the right ages
• C. D
• D. Enberg conforms to standards for prescribing controlled substances
• E. The condition of one of D
• F. Enberg's patients improved after the patient received medical treatment from D
• G. Enberg
• H. D
• I. Enberg's procedures are adequate for ensuring patients' access to medical care

Answer: A

NEW QUESTION 2

CMS Medicare+Choice regulations include a provision that allows health plans to deny benefits for any services the health plan objects to on moral or religious grounds. The provision that exempts health plans from providing such services is known as

• A. a conscience protection exception
• B. a hold harmless clause
• C. a medical necessity determination
• D. an intermediate sanction

Answer: A

NEW QUESTION 3

The following statement(s) can correctly be made about contracting and reimbursement of specialty care physicians (SCPs):

• A. Typically, a health plan should attempt to control utilization of SCPs before attempting to place these providers under a capitation arrangement.
• B. Forms of specialty physician reimbursement used by health plans include a retainer and a bundled case rate.
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: A

NEW QUESTION 4

Dr. Eve Barlow is a specialist in the Amity Health Plan’s provider network. Dr. Barlow’s provider contract with Amity contains a typical most-favored-nation arrangement. The purpose of this arrangement is to

• A. Require D
• B. Barlow and Amity to use arbitration to resolve any disputes regarding the contract
• C. Specify that the contract is to be governed by the laws of the state in which Amity has its headquarters
• D. Require D
• E. Barlow to charge Amity her lowest rate for a medical service she has provided to an Amity plan member, even if the rate is lower than the price negotiated in the contract
• F. State that the contract creates an employment or agency relationship, rather than an independent contractor relationship, between D
• G. Barlow and Amity

Answer: C

NEW QUESTION 5

Stop-loss insurance is designed to protect physicians who face substantial financial risk as a result of physician incentive plans. Medicare+Choice health plans must ensure that a physician has adequate stop-loss protection if the

• A. physician has a patient panel that exceeds 25,000 patients
• B. physician receives a bonus that is based solely on quality of care, patient satisfaction, or physician participation
• C. difference between the physician’s maximum potential payments and his or her minimum potential payments is less than 25% of the maximum potential payments
• D. physician is subject to a withhold that is greater than 25% of his or her potential payments

Answer: D

NEW QUESTION 6

One true statement about the Employee Retirement Income Security Act of 1974 (ERISA) is that:

• A. ERISA applies to all issuers of health insurance products, such as HMOs
• B. pension plans and employee welfare plans are exempt from any regulation under ERISA
• C. ERISA requires self-funded plans to comply with all state mandates affecting health insurance companies and health plans
• D. the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plans

Answer: D

NEW QUESTION 7

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.
The comparative method of evaluation that Azure uses to identify and implement the practices that lead to the best outcomes is known as

• A. Case mix analysis
• B. Outcomes research
• C. Benchmarking
• D. Provider profiling

Answer: C

NEW QUESTION 8

The provider contract that Dr. Laura Cartier has with the Sailboat health plan includes a section known as the recitals. Dr. Cartier's contract includes the following statements:

• A. A statement that identifies the purpose of the contract
• B. A statement that defines in legal terms the parties to the contract
• C. A statement that identifies the Sailboat products to be covered by the contractOf these statements, the ones that are likely to be included in the recitals section of D
• D. Cartier's contract are statements:
• E. A, B, and C
• F. A and B only
• G. A and C only
• H. B and C only

Answer: A

NEW QUESTION 9

Social health maintenance organizations (SHMOs) and Programs of All-Inclusive Care for the Elderly (PACE) are federal programs designed to provide coordinated healthcare services to the elderly. Unlike PACE, SHMOs

• A. are reimbursed solely through Medicaid programs
• B. provide extensive long-term care
• C. are reimbursed on a fee-for-service basis
• D. limit benefits to a specified maximum amount

Answer: D

NEW QUESTION 10

The following statement(s) can correctly be made about the Balanced Budget Act (BBA) of 1997:

• A. The BBA requires Medicare+Choice organizations to be licensed as non-risk-bearing entities under federal law.
• B. The Centers for Medicaid and Medicare Services (CMS) is responsible for implementing the BBA.
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: C

NEW QUESTION 11

The Omni Health Plan is interested in expanding the specialty services it offers to its plan members and is considering contracting with the following providers of specialty services:
The Apex Company, a managed vision care organization (MVCO) The Baxter Managed Behavioral Healthcare Organization (MBHO) The Cheshire Dental Health Maintenance Organization (DHMO)
As part of its credentialing process, Omni would like to verify that each of these providers has met NCQA’s accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for

• A. Apex and Baxter only
• B. Apex and Cheshire only
• C. Baxter and Cheshire only
• D. Baxter only

Answer: D

NEW QUESTION 12

Health plan contract negotiations with an integrated delivery system (IDS) or a hospital are usually lengthier and more complex than negotiations with a single-specialty provider.

• A. True
• B. False

Answer: A

NEW QUESTION 13

The following statements are about fee-for-service (FFS) payment systems. Select the answer choice containing the correct statement:

• A. A discounted fee-for-service (DFFS) system is usually easier for a health plan to administer than is a fee schedule system.
• B. A case rate payment system offers providers an incentive to take an active role in managing cost and utilization.
• C. One reason that health plans use a relative value scale (RVS) payment system is that RVS values for cognitive services have traditionally been higher than the values for procedural services.
• D. One reason that health plans use a resource-based relative value scale (RBRVS) is that this system includes weighted unit values for all types of procedures.

Answer: B

NEW QUESTION 14

The Enterprise Health Plan has indicated an interest in delegating its medical records review activities to the Teal Group and has forwarded a typical letter of intent to Teal. One true statement about this letter of intent is that it:

• A. Is a contract that creates a legally binding relationship between Enterprise and Teal
• B. Cannot include a confidentiality clause
• C. Serves as a delegation agreement between Enterprise and Teal
• D. Outlines the delegation oversight process

Answer: D

NEW QUESTION 15

Although a health plan is allowed to delegate many activities to outside sources, the National Committee for Quality Assurance (NCQA) has determined that some activities are not delegable.
These activities include

• A. evaluation of new medical technologies
• B. overseeing delegated medical records activities
• C. developing written statements of members’ rights and responsibilities
• D. all of the above

Answer: D

NEW QUESTION 16

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement.
One important activity within the scope of network management is ensuring the quality of the health plan’s provider networks. A primary purpose of ________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan’s preestablished criteria for participation in the network.

• A. authorization
• B. provider relations
• C. credentialing
• D. utilization management

Answer: C

NEW QUESTION 17

Dr. Sarah Carmichael is one of several network providers who serve on one of the Apex Health Plan’s organizational committees. The committee reviews cases against providers identified through complaints and grievances or through clinical monitoring activities. If needed, the committee formulates, approves, and monitors corrective action plans for providers. Although Apex administrators and other employees also serve on the committee, only participating providers have voting rights. The committee that Dr. Carmichael serves on is a

• A. Utilization management committee
• B. Peer review committee
• C. Medical advisory committee
• D. Credentialing committee

Answer: B

NEW QUESTION 18

Participating providers in a health plan’s network must undergo recredentialing on a regular basis. During recredentialing, a health plan typically reviews

• A. a provider’s current, updated application information, as well as provider’s peer reviews and performance reports on the provider
• B. a provider’s current, updated application information, as well as the provider’s education and prior work history
• C. a provider’s education and prior work history only
• D. peer reviews and performance reports on a provider and the provider’s prior work history only

Answer: A

NEW QUESTION 19
......