Vivid AHIP AHM-540 Real Exam Online

NEW QUESTION 1
Acute care refers to healthcare services for medical problems that

• A. are expected to continue for a minimum of 30 days
• B. are typically treated in a provider’s office or outpatient facility
• C. require prompt, intensive treatment by healthcare providers
• D. require low utilization of resources

Answer: C

NEW QUESTION 2
The Brighton Health Plan regularly performs prospective UR for surgical procedures. Brighton’s prospective UR activities are likely to include

• A. documenting the clinical details of the patient’s condition and care
• B. tracking the length of inpatient stay
• C. completing the discharge planning process
• D. determining the most appropriate setting for the proposed course of care

Answer: D

NEW QUESTION 3
Some health plans administer a questionnaire known as the Behavioral Risk Factor Surveillance System (BRFSS) as part of their health risk assessment (HRA) processes. The following statements are about the BRFSS. If statements (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct statement.

• A. This questionnaire was designed specifically for use by health plans.
• B. Each health plan must use the same form of the questionnaire, with no additions or modifications.
• C. This questionnaire monitors the prevalence of the major behavioral risks associated with illness and injury among adults.
• D. All of the above statements are correct.

Answer: C

NEW QUESTION 4
The Glenway Health Plan’s pharmacy and therapeutics (P&T) committee conducted pharmacoeconomic research to measure both the clinical outcomes and costs of two new cholesterol-reducing drugs. Results were presented as a ratio showing the cost required to produce a 1 mcg/l decrease in cholesterol levels. The type of pharmacoeconomic research that Glenway conducted in this situation was most likely

• A. cost-effectiveness analysis (CEA)
• B. cost-minimization analysis (CMA)
• C. cost-utility analysis (CUA)
• D. cost of illness analysis (COI)

Answer: A

NEW QUESTION 5
The nature of behavioral healthcare creates unique medical management challenges for health plans. One method health plans have used to support the delivery of appropriate services in a cost-effective manner is to

• A. remove behavioral healthcare services from the primary care setting
• B. shift behavioral healthcare from acute inpatient settings to alternative settings when feasible
• C. reserve the use of psychotherapy for treatment of those conditions that persist over long periods of time or for the life of the patient
• D. offer the same level of compensation to all of the professional disciplines that provide behavioral healthcare services to plan members

Answer: B

NEW QUESTION 6
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
Medical management programs often require the analysis of many types of data and information. ________ is an automated process that analyzes variables to help detect patterns and relationships in the data.

• A. Unbundling
• B. Outsourcing
• C. Data mining
• D. Drilling down

Answer: C

NEW QUESTION 7
Increased demands for performance information have resulted in the development of various health plan report cards. With respect to most of the report cards currently available, it is correct to say

• A. that they are focused primarily on health maintenance organization (HMO) plans
• B. that they are based on data collected for the Health Plan Employer Data and Information Set (HEDIS) 3.0
• C. that they are used to rank the performance of various health plans
• D. all of the above

Answer: D

NEW QUESTION 8
A health plan’s coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions:
* 1. In case of conflict between the purchaser contract and a health plan’s medical policy or benefits administration policy, the contract takes precedence
* 2. Purchaser contracts commonly exclude custodial care from their coverage of services and supplies
* 3. All of the criteria for coverage decisions must be included in the purchaser contract

• A. All of the above
• B. 1 and 2 only
• C. 2 only
• D. 3 only

Answer: B

NEW QUESTION 9
Federal laws, such as the Employee Retirement Income Security Act (ERISA), the Balanced Budget Act (BBA) of 1997, and the Health Insurance Portability and Accountability Act (HIPAA), have affected medical management activities by health plans. Consider the following provisions of federal regulations:
Provision 1—Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered treatment and does not allow health plan members to obtain compensatory or punitive damages
Provision 2—Establishes electronic data security standards, which define the security measures that healthcare organizations must take to protect the confidentiality of electronically stored and transmitted patient information From the answer choices below, select the response that correctly identifies the federal laws that include Provision 1 and Provision 2, respectively.

• A. Provision 1- ERISA Provision 2- HIPAA
• B. Provision 1- HIPAA Provision 2- ERISA
• C. Provision 1- BBA of 1997 Provision 2- HIPAA
• D. Provision 1- ERISA Provision 2- BBA of 1997

Answer: A

NEW QUESTION 10
The following statements are about QAPI as it applies to Medicare+Choice plans and Medicaid health plan entities. Select the answer choice containing the correct statement.

• A. QAPI provides separate sets of standards for Medicaid MCEs and Medicare+Choice plans.
• B. Medicaid primary care case management (PCCM) programs are required to comply with all QAPI standards.
• C. QISMC standards for quality measurement and improvement apply only to clinical services delivered to Medicare and Medicaid enrollees.
• D. States that require Medicaid MCEs to comply with QAPI standards are considered to be in compliance with CMS quality assessment and improvement regulations.

Answer: D

NEW QUESTION 11
The paragraph below contains two pairs of phrases enclosed in parentheses. Select the phrase in each pair that correctly completes the paragraph. The select the answer choice containing the two phrases you have selected.
Calvin Montrose, age 75, has difficulty performing basic self-care activities, such as bathing, dressing, and eating, without assistance. This information indicates that Mr. Montrose needs assistance with (activities of daily living / instrumental activities of daily living) that are used to measure his (functional status / health status).

• A. activities of daily living / functional status
• B. activities of daily living / health status
• C. instrumental activities of daily living / functional status
• D. instrumental activities of daily living / health status

Answer: A

NEW QUESTION 12
Among this agency’s accreditation programs are accreditation for preferred provider organizations (PPOs), health plan call centers, and case management organizations. This agency classifies its standards as either “shall” standards or “should” standards.

• A. American Accreditation HealthCare Commission/URAC (URAC)
• B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• C. Community Health Accreditation Program (CHAP)
• D. National Committee for Quality Assurance (NCQA)

Answer: A

NEW QUESTION 13
Determine whether the following statement is true or false:
With respect to the size of a managed care organization (MCO) and its medical management operations, it is correct to say that large health plans typically have more integration among activities and less specialization of roles than do small MCOs.

• A. True
• B. False

Answer: B

NEW QUESTION 14
To see that utilization guidelines are consistently applied, UR programs rely on authorization systems. Determine whether the following statement about authorization systems is true or false:
Only physicians can make nonauthorization decisions based on medical necessity.

• A. True
• B. False

Answer: A

NEW QUESTION 15
The Harbor Health Plan’s formulary policy encourages network pharmacists who are asked to fill a prescription for a costly, brand-name drug to dispense a different chemical entity within the same drug class in order to reduce costs. This type of drug substitution is referred to as

• A. generic substitution, and prescriber approval is not required
• B. generic substitution, and prescriber approval is always required
• C. therapeutic substitution, and prescriber approval is not required
• D. therapeutic substitution, and prescriber approval is always required

Answer: D

NEW QUESTION 16
Patient safety and medical errors are important concerns for both quality management (QM) and risk management. The following statement(s) can correctly be made about medical errors:
* 1. The complexity of modern medicine and healthcare delivery systems increases patients’ exposure to the risks of medical errors
* 2. Licensing boards for healthcare professionals in all states provide a consistent system of quality oversight and accountability
* 3. Provider compliance with internal incident reporting requirements is low

• A. All of the above
• B. 1 and 2 only
• C. 1 and 3 only
• D. 3 only

Answer: C

NEW QUESTION 17
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.
The Millway Health Plan received a 15% reduction in the price of a particular pharmaceutical based on the volume of the drug Millway purchased from the manufacturer. This reduction in price is an example of a (rebate / price discount) and (is / is not) dependent on actual provider prescribing patterns.

• A. rebate / is
• B. rebate / is not
• C. price discount / is
• D. price discount / is not

Answer: D

NEW QUESTION 18
This agency’s accreditation decisions are based on the results of an on-site survey of clinical and administrative systems and processes, as well as the health plan’s performance on selected effectiveness of care and member satisfaction measures.

• A. American Accreditation HealthCare Commission/URAC (URAC)
• B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• C. Community Health Accreditation Program (CHAP)
• D. National Committee for Quality Assurance (NCQA)

Answer: D

NEW QUESTION 19
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
To manage the delivery of healthcare services to their members, health plans use clinical practice parameters. _________ is the type of clinical practice parameter that a health plan uses to make coverage decisions concerning medical necessity and appropriateness.

• A. A clinical practice guideline (CPG)
• B. Medical policy
• C. Benefits administration policy
• D. A standard of care

Answer: B

NEW QUESTION 20
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
Definitions of quality healthcare vary; however, four dimensions are essential to quality healthcare services. _____ is the quality dimension indicating that services result in the best care for a given cost or the lowest cost for a given level of care.

• A. Accessibility
• B. Effectiveness
• C. Acceptability
• D. Efficiency

Answer: D

NEW QUESTION 21
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