How Many Questions Of AHM-530 Practice Exam

NEW QUESTION 1

The employees of the Trilogy Company are covered by a typical workers' compensation program. Under this coverage, Trilogy employees are bound by the exclusive remedy doctrine, which most likely:

• A. Allows Trilogy to deny benefits for an employee's on-the-job injury or illness, but only if Trilogy is not at fault for the injury or illness.
• B. Allows Trilogy to place limits on the amount of coverage payable for a given claim under the workers' compensation program.
• C. Requires the employees to accept workers' compensation as their only compensation in cases of work-related injury or illness.
• D. Provides the employees with 24-hour coverage.

Answer: C

NEW QUESTION 2

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 3

By definition, a measure of the extent to which a health plan member can obtain necessary medical services in a timely manner is known as

• A. Network management
• B. Quality
• C. Cost-effectiveness
• D. Accessibility

Answer: D

NEW QUESTION 4

Under the compensation arrangement that the Falcon Health Plan has with some of its providers, Falcon holds back 10% of the negotiated payments to these providers in order to offset or pay for any claims that exceed the budgeted costs for referral or hospital services. If the providers keep costs within the budgeted amount, Falcon distributes to them the entire amount of money held back. This way of motivating providers to control costs while providing high-quality, appropriate care is known as a:

• A. Risk pool arrangement
• B. Withhold arrangement
• C. Cost-shifting arrangement
• D. Bonus pool arrangement

Answer: B

NEW QUESTION 5

Franklin Pitt selected a Medicare+Choice option under which he is covered by a catastrophic health insurance policy with a high annual deductible and a $6,000 out-of- pocket expense maximum. CMS pays the premiums for the insurance policy out of the usual Medicare+Choice payment and deposits any difference between the capitated amount and the policy premium in a savings account. Mr. Pitt can use funds in the savings account to pay qualified medical expenses not covered by his insurance policy. At the end of the benefit year, Mr. Pitt can carry any remaining funds into the next benefit year. The Medicare+Choice option Mr. Pitt selected is known as a

• A. coordinate care plan (CCP)
• B. medical savings account (MSA) plan
• C. competitive medical plan (CMP)
• D. Medicare Risk HMO program

Answer: B

NEW QUESTION 6

In most states, workers’ compensation is first-dollar and last-dollar coverage, which means thatworkers’ compensation programs

• A. Can place limits on the benefits they will pay for a given claim
• B. Can deny coverage for work-related illness or injury if the employer is not at fault
• C. Must pay 100% of work-related medical and disability expenses
• D. Can hold employers liable for additional amounts that result from court decisions

Answer: C

NEW QUESTION 7

Edward Patillo has established a Medicare+Choice medical savings account (MSA). This MSA will allow Mr. Patillo to:

• A. Carry over any money remaining in his MSA at the end of the benefit year to the next benefit year
• B. Make withdrawals at any time from the MSA, but only for medical expenses
• C. Obtain payment at 100% of the Medicare allowable payment for all Medicare-covered services he receives, without having to pay any deductibles or out-of-pocket expenses
• D. Make withdrawals from the MSA to meet qualified medical expenses that are not paid by his high-deductible health insurance policy, but these withdrawals are taxed as income to M
• E. Patillo

Answer: A

NEW QUESTION 8

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 9

Dr. Leona Koenig removed the appendix of a plan member of the Helium health plan. In order to increase the level of reimbursement that she would receive from Helium, Dr. Koenig submitted to the health plan separate charges for the preoperative physical examination, the surgicalprocedure, and postoperative care. All of these charges should have been included in the code for the surgical procedure itself. Dr. Koenig's submission is a misuse of the coding system used by health plans and is an example of:

• A. Upcoding
• B. A wrap-around
• C. Churning
• D. Unbundling

Answer: D

NEW QUESTION 10

The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:

• A. Must provide Medicare participants with standard HMO benefits, as well as with limited long-term care benefits
• B. Does not need as great a variety of provider types or as complex a reimbursement method as does a traditional HMO
• C. Receives a payment that is based on reasonable costs and reasonable charges
• D. Most likely provides fewer supportive services than does a traditional HMO, because one of Bruin's goals is to minimize the use of community-based care

Answer: A

NEW QUESTION 11

The following statements are about the inclusion of unified pharmacy benefits in health plan healthcare packages. Select the answer choice containing the correct statement.

• A. When pharmacy benefits management is incorporated into an health plan’s operations as a unified benefit, the health plan establishes pharmacy networks, but a pharmacy benefits management (PBM) company manages their operations.
• B. Under a unified pharmacy benefit, an health plan cannot use mail-order services to provide drugs to its members.
• C. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs typically give health plans more control over patient access to prescription drugs.
• D. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs make drug therapy interventions for plan members more difficult.

Answer: C

NEW QUESTION 12

Four types of APCs are ancillary APCs, medical APCs, significant procedure APCs, and surgical APCs. An example of a type of APC known as

• A. An ancillary APC is a biopsy
• B. Amedical APC is radiation therapy
• C. Asignificant procedure APC is a computerized tomography (CT) scan
• D. Asurgical APC is an emergency department visit for cardiovascular disease

Answer: C

NEW QUESTION 13

When evaluating the success of providers in meeting standards, a health plan must make adjustments for case mix or severity. One true statement about case mix/severity adjustments is that they:

• A. Typically are more important in measuring the performance of PCPs than they are in measuring the performance of specialists
• B. Help compensate for any unusual factors that may exist in a provider's patient population or in a particular patient
• C. Tend to increase the number of providers who are considered to be outliers
• D. Allow for a more equitable comparison of data between providers of outpatient care but not providers of inpatient care

Answer: B

NEW QUESTION 14

Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be

• A. $42,857
• B. $56,700
• C. $272,160
• D. $680,400

Answer: C

NEW QUESTION 15

The following statements are about workers' compensation provider networks. Select the answer choice containing the correct statement:

• A. In order to supply a provider network to furnish healthcare to workers' compensation beneficiaries, a health plan typically uses the network that has already been created for the group health plan.
• B. Typically, case managers for workers' compensation programs are physical therapists.
• C. Most states prohibit the use of fee schedules in order to curb the rising workers' compensation healthcare costs.
• D. Networks serving workers' compensation patients typically include higher concentrations of specialists than do other provider networks.

Answer: D

NEW QUESTION 16

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 17

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 18

The following statement(s) can correctly be made about financial arrangements between health plans and emergency departments of hospitals:

• A. These arrangements typically include payments for services rendered in the emergency department by a health plan's primary or specialty care providers.
• B. Most of these arrangements are structured through the health plan's contract with the hospital.
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: C

NEW QUESTION 19

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 20
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