Abreast Of The Times AHM-530 Exam Topics For Network Management Certification

NEW QUESTION 1

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 2

The following statements are about some of the issues surrounding the contractual responsibilities of health plans. Select the answer choice containing the correct statement.

• A. Typically, health plans are required to pay completed claims within 10 days of submission.
• B. Health plans typically are prohibited from examining the financial soundness of a self- funded employer plan that relies on the health plan to pay providers for services received by the plan’s members.
• C. Patient delivery is one of the most significant factors that health plans consider when determining whether provider services should be reimbursed on a capitated or fee-for- service (FFS) basis.
• D. Health plans require all providers to agree to an exclusive provider contract.

Answer: C

NEW QUESTION 3

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 4

Partial capitation is one common approach to capitation. One typical characteristic of partial capitation is that it:

• A. Includes only primary care services
• B. Covers such services as immunizations and laboratory tests
• C. Can be used only if the provider's panel size is less than 50 providers
• D. Covers such services as cardiology and orthopedics

Answer: A

NEW QUESTION 5

The Blanchette Health Plan uses a method of claims submission that allows its providers to submit claims directly to Blanchette through a computer application-to-application exchange of claims using a standard data format. This information indicates that Blanchette allows its providers to submit claims using technology known as

• A. Telemedicine
• B. An electronic referral system
• C. Electronic data interchange
• D. Encounter reporting

Answer: C

NEW QUESTION 6

Health plans can often reduce workers’ compensation costs by incorporating 24-hour coverage into their workers’ compensations programs. Twenty-four-hour coverage reduces costs by

• A. Maximizing the effects of cost shifting
• B. Eliminating the need for utilization management
• C. Requiring members to use separate points of entry for job-related and non-job related services
• D. Combining administrative services for workers’ compensation and non-workers’ compensation healthcare and disability coverage

Answer: D

NEW QUESTION 7

From the following answer choices, choose the term that best matches the description.
An integrated delivery system (IDS), which controls most providers in a particular specialty, agrees to provide that specialty service to a health plan only on thecondition that the health planagree to contract with the IDS for other services.

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

Answer: C

NEW QUESTION 8

Dr. Janet Dubois is a radiologist who practices exclusively at the Rightway Healthcare Center. This information indicates that Dr. Dubois is employed by Rightway as

• A. An academic practitioner
• B. An independent practitioner
• C. Anetwork manager
• D. Ahospital-based specialist

Answer: D

NEW QUESTION 9

The Avignon Company discontinued its contract with a traditional indemnity insurer and contracted exclusively with the Minaret Health Plan to provide the sole healthcare plan to Avignon’s employees. By agreeing to an exclusive contract with Minaret, Avignon has entered into a type of healthcare contract known as

• A. a carrier guarantee arrangement
• B. open access
• C. total replacement coverage
• D. selective contract coverage

Answer: C

NEW QUESTION 10

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.
To calculate its drug costs, Elm uses a pricing system known as:

• A. Estimated acquisition cost (EAC)
• B. Package rate cost (PRC)
• C. Actual acquisition cost (AAC)
• D. Wholesale acquisition cost (WAC)

Answer: A

NEW QUESTION 11

An health plan enters into a professional services capitation arrangement whenever the health plan

• A. Contracts with a medical group, clinic, or multispecialty IPA that assumes responsibility for the costs of all physician services related to a patient’s care
• B. Pays individual specialists to provide only radiology services to all plan members
• C. Transfers all financial risk for healthcare services to a provider organization and the provider, in turn, covers virtually all of a patient’s medical expenses
• D. Contracts with a primary care provider to cover primary care services only

Answer: A

NEW QUESTION 12

The Brice Health Plan submitted to Clarity Health Services a letter of intent indicating Brice’s desire to delegate its demand management function to Clarity. One true statement about this letter of intent is that it

• A. creates a legally binding relationship between Brice and Clarity
• B. most likely contains a confidentiality clause committing Brice and Clarity to maintain theconfidentiality of documents reviewed and exchanged in the process
• C. prohibits Clarity from performing similar delegation activities for other health plans
• D. most likely contains a detailed description of the functions that Brice will delegate to Clarity

Answer: B

NEW QUESTION 13

Reimbursement for prescription drugs and services in a third-party prescription drug plan typically follows one of two approaches: a reimbursement approach or a service approach. One true statement about these approaches is that:

• A. Payments under the reimbursement method typically are not subject to any copayment or deductible requirements
• B. Payments under the reimbursement approach are typically based on a structured reimbursement schedule rather than on usual, customary, and reasonable (UCR) charges
• C. Most major medical plans follow a service approach
• D. Most current health plan prescription drug plans are service plans

Answer: D

NEW QUESTION 14

In developing a provider network in an large city with a high concentration of young families, the Gypsum Health Plan has set goals focused on the needs of that particular market. The following statements are about this situation. Three of the statements are true, and one of the statements is false. Select the answer choice that contains the FALSE statement.

• A. Gypsum should attempt to recruit providers who offer extended office hours.
• B. Gypsum can use the cost-effectiveness of its own existing networks as a benchmark for its cost-savings goals in this market.
• C. Gypsum will most likely attempt to contract with HMOs.
• D. Gypsum most likely should set lower cost-savings goals in this market than it would in a rural market with few young families.

Answer: D

NEW QUESTION 15

The provider contract that Dr. Bijay Patel has with the Arbor Health Plan includes a no- balance-billing clause. The purpose of this clause is to:

• A. prohibit D
• B. Patel from collecting payments from Arbor plan members for medical services that he provided them, even if the services are explicitly excluded from the benefit plan
• C. allow D
• D. Patel to bill patients for services only if the services are considered to be medically necessary
• E. establish the guidelines used to determine if Arbor is the primary payor of benefits in a situation in which an Arbor plan member is covered by more than one health plan
• F. require D
• G. Patel to accept Arbor's payment as payment in full for medical services that he provides to Arbor plan members

Answer: D

NEW QUESTION 16

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 17

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 18

The two basic approaches that Medicaid uses to contract with health plans are open contracting and selective contracting. One true statement about these approaches to contracting is that:

• A. Open contracting requires health plans to meet minimum performance standards outlined in a state's request for proposal (RFP)
• B. Open contracting makes it possible for the Medicaid agency to offer enrollment volume guarantees
• C. Selective contracting requires any health plan that meets the state's performance standards and the federal Medicaid requirements to enter into a Medicaid contract
• D. Selective contracting requires health plans to bid competitively for Medicaid contracts

Answer: D

NEW QUESTION 19

Following statements are about accreditation of health plans:

• A. The National Committee for Quality Assurance (NCQA) serves as the primary accrediting agency for most health maintenance organizations (HMOs).
• B. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has developed standards that can be used for the accreditation of hospitals, but not for the accreditation of health plan provider networks or health plan plans.
• C. States are required to adopt the model standards developed by the National Association of Insurance Commissioners (NAIC), an organization of state insurance regulators that develops standards to promote uniformity in insurance regulations.
• D. Accreditation is an evaluative process in which a health plan undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the federal government or by the state governments.

Answer: A

NEW QUESTION 20
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