How Many Questions Of AHM-530 Exam

NEW QUESTION 1

From the following answer choices, choose the term that best matches the description.
Members of a physician-hospital organization (PHO) denied membership to a physician solely because the physician has admitting privileges at a competing hospital.

• A. Group boycott
• B. Horizontal division of territories
• C. Tying arrangements
• D. Concerted refusal to admit

Answer: A

NEW QUESTION 2

The vision benefits offered by the Omni Health Plan include clinical eye care only. The following statements describe vision care received by Omni plan members:
•Brian Pollard received treatment for a torn retina he suffered as a result of an accident
•Angelica Herrera received a general eye examination to test her vision
•Megan Holtz received medical services for glaucoma
Of these medical services, the ones that most likely would be covered by Omni's vision coverage would be the services received by:

• A. M
• B. Pollard, M
• C. Herrera, and M
• D. Holtz
• E. M
• F. Pollard and M
• G. Herrera only
• H. M
• I. Pollard and M
• J. Holtz only
• K. M
• L. Herrera and M
• M. Holtz only

Answer: C

NEW QUESTION 3

One characteristic of the workers' compensation program is that:

• A. workers' compensation coverage is available to all employees, regardless of their eligibility for health insurance coverage
• B. indemnity benefits currently account for less than 10% of all workers' compensation benefits
• C. workers' compensation programs in most states require eligible employees to obtain medical treatment only from members of a provider network
• D. workers' compensation programs include deductibles and coinsurance requirements

Answer: A

NEW QUESTION 4

In most health plan pharmacy networks, the cost component of the reimbursement formula is based on the average wholesale price (AWP). One true statement about the AWP for prescription drugs is that

• A. AWPs tend to vary widely from region to region of the United States
• B. The AWP is often substantially higher than the actual price the pharmacy pays for prescription drugs
• C. A health plan’s contracted reimbursement to a pharmacy for prescription drugs is typically the AWP plus a percentage, such as 5%
• D. The AWP usually is lower than the estimated acquisition cost (EAC) for most prescription drugs

Answer: B

NEW QUESTION 5

The following statements are about the delegation of network management activities from a health plan to another party. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:

• A. The NCQA requires a health plan to conduct all delegation oversight functions rather than delegating the responsibility for oversight to another entity.
• B. Credentialing and UM activities are the most frequently delegated functions, whereas delegation is less common for quality management (QM) and preventive health services.
• C. One reason that a health plan may choose to delegate a function is because the health plan's staff seeks external expertise for the delegated activity.
• D. When the health plan delegates authority for a function, it transfers the power to conduct the function on a day-to-day basis, as well as the ultimate accountability for the function.

Answer: D

NEW QUESTION 6

The Medea Clinic is a network provider for Delphic Healthcare. Delphic transferred the contract it held with Medea to the Elixir HMO, an entity that was not party to the original contract. The process by which Delphic transferred the contract it held with Medea to Elixir is known as

• A. Most-favored- nation arrangement
• B. Alimit on action
• C. Aconsideration
• D. An assignment

Answer: D

NEW QUESTION 7

The Portway Hospital is qualified to receive Medicaid subsidy payments as a disproportionate share hospital (DHS). The DHS payments that Portway receives are

• A. Made for services rendered to specific patients
• B. Made with matching state and federal funds
• C. Included in the Medicaid capitation payment made to patients’ health plans
• D. Defined as cost-based reimbursement (CBR) equal to 100% of Portway’s reasonable costs of providing services to Medicaid recipients

Answer: B

NEW QUESTION 8

Grant Pelham is covered by both a workers’ compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.
Because Mr. Pelham was injured on the job, he is entitled to receive benefits through workers’ compensation. Under the terms of the state-mandated exclusive remedy doctrine included in the workers’ compensation agreement, Mr. Pelham will most likely be prohibited from

• A. Receiving workers’ compensation benefits unless he can show that the employer was at fault for his injury
• B. Obtaining care from providers who are not members of a workers’ compensation network
• C. Suing his employer for additional benefits
• D. Claiming benefits from both workers’ compensation and his group health plan

Answer: C

NEW QUESTION 9

Martin Breslin, age 72 and permanently disabled, is classified as dually-eligible. This information indicates that Mr. Breslin qualifies for coverage by both

• A. Medicare and private indemnity insurance, and Medicare provides primary coverage
• B. Medicare and Medicaid, and Medicare provides primary coverage
• C. Medicaid and private indemnity insurance, and Medicaid provides primary coverage
• D. Medicare and Medicaid, and Medicaid provides primary coverage

Answer: B

NEW QUESTION 10

The introductory paragraph of a provider contract is generally followed by a section called the recitals. The recitals section of the contract typically specifies the

• A. Purpose of the agreement
• B. Manner in which the provider is to bill for services
• C. Definitions of key terms to be used in the contract
• D. Rate at which the provider will be compensated

Answer: A

NEW QUESTION 11

In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it

• A. Applies to group health insurance plans only
• B. Limits the length of a health plan’s pre-existing condition exclusion period for a previously covered individual to a maximum of six months after enrollment.
• C. Guarantees access to healthcare coverage for small businesses and previously covered individuals who meet specified eligibility requirements.
• D. Guarantees renewability of group and individual health coverage, provided the insureds are still in good health

Answer: C

NEW QUESTION 12

Health plans often negotiate compensation arrangements that transfer some or all of the financial risk associated with delivering healthcare services to network providers. The following statements are about these compensation arrangements. Select the answer choice containing the correct statement.

• A. A per diem system typically places a healthcare facility at risk for controlling utilization and costs internally.
• B. One likely reason that an health plan would use a fee schedule system to compensate providers is that this system transfers most of the financial risk to the provider.
• C. Under a salary system, a provider assumes no service risk.
• D. The use of a FFS or a salary system allows an health plan to transfer a greater proportion of financial risk to providers than does the use of capitation.

Answer: A

NEW QUESTION 13

When the Rialto Health Plan determines which of the emergency services received by its plan members should be covered by the health plan, it is guided by a standard which describes emergencies as medical conditions manifesting themselves by acute symptoms of sufficient severity (including severe pain) such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy. This standard, which was adopted by the NAIC in 1996, is referred to as the

• A. medical necessity standard
• B. prudent layperson standard
• C. “all-or-none” standard
• D. reasonable and customary standard

Answer: B

NEW QUESTION 14

The Ross Health Plan compensates Dr. Cecile Sanderson on a FFS basis. In order to increase the level of reimbursement that she would receive from Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The services she actually provided represented an intermediate level of service. Dr. Sanderson’s action is an example of a type of false billing procedure known as

• A. Cost shifting
• B. Churning
• C. Unbundling
• D. Upcoding

Answer: D

NEW QUESTION 15

The following statement(s) can correctly be made about hospitalists.
* 1. The hospitalist’s main function is to coordinate diagnostic and treatment activities to ensure that the patient receives appropriate care while in the hospital.
* 2. The hospitalist’s role clearly supports the health plan concept of disease management.

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: B

NEW QUESTION 16

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 NewnanGroup, 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.
The following statements can correctly be made about the reimbursement for Drugs A and B under the MAC pricing system:

• A. Treble most likely is obligated to reimburse Manor 14 cents per tablet for Drug A.
• B. Manor most likely is allowed to bill the subscriber 2 cents per tablet for Drug A.
• C. Treble most likely is obligated to reimburse Manor 5 cents per tablet for Drug B.
• D. All of the above statements are correct.

Answer: C

NEW QUESTION 17

As part of the credentialing process, many health plans use the National Practitioner Data Bank (NPDB) to learn information about prospective members of a provider network. One true statement about the NPDB is that:

• A. It is maintained by the individual states
• B. It primarily includes information about any censures, reprimands, or admonishments against any physicians who are licensed to practice medicine in the United States
• C. The information in the NPDB is available to the general public
• D. It was established to identify and discipline medical practitioners who act unprofessionally

Answer: D

NEW QUESTION 18

Open panel health plans can contract with individual providers or with various provider groups when developing their networks. The following statements are about factors that an open panel health plan might consider in contracting with different types of provider organizations. Select the answer choice that contains the correct statement.

• A. One limitation of contracting with multispecialty groups is that a health plan obtains only specialty consultants, but not PCPs.
• B. One benefit to a health plan in contracting with an integrated delivery system (IDS) is the ability to have a network in rapid order and to enter into a new market or one that is already competitive.
• C. A health plan that contracts with an individual practice association (IPA) has a greater ability to select and deselect individual physicians than when contracting directly with the providers.
• D. A health plan that contracts with an IDS is able to eliminate the antitrust risk that exists when contracting with an IPA.

Answer: B

NEW QUESTION 19
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