A Review Of Approved AHM-540 Free Exam Questions

NEW QUESTION 1
Many health plans use clinical pathways to help manage the delivery of acute care services to plan members. One true statement about clinical pathways is that they

• A. determine which healthcare services are medically necessary and appropriate for a particular patient in a particular situation
• B. outline the services that will be delivered, the providers responsible for delivering the services, the timing of delivery, the setting in which services are delivered, and the expected outcomes of the interventions
• C. cover only services delivered in an acute inpatient setting
• D. address medical conditions that affect a small segment of a given population and with which the majority of providers are unfamiliar

Answer: B

NEW QUESTION 2
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 3
Health plans have a specified number of working days to respond to Level One appeals, as stated by company policy or regulatory requirements. With regard to the timeframes for appeals, it is generally correct to say
* 1. That the typical timeframe requires a health plan to respond to appeals in fewer than 20 days
* 2. That the timeframe is accelerated for expedited appeals
* 3. That the review period begins when the appeal arrives at a health plan

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

Answer: D

NEW QUESTION 4
To facilitate electronic commerce (eCommerce), a health plan may establish a secured extranet. One true statement about a secured extranet is that it is

• A. based on Web-based technologies
• B. available only to the employees of the health plan
• C. publicly available, so the potential exists for unauthorized access to a health plan’s proprietary systems
• D. used to handle the majority of health plan eCommerce

Answer: A

NEW QUESTION 5
As a follow-up to a performance improvement plan for member services, the Stellar Health Plan conducted an evaluation of the success of the plan. Stellar conducted its evaluation as the plan was being carried out. The evaluation focused on specific activities and assessed the relative importance of those activities to the plan as a whole. This information indicates that Stellar’s evaluation of the plan was both

• A. concurrent and formative
• B. concurrent and summative
• C. retrospective and formative
• D. retrospective and summative

Answer: A

NEW QUESTION 6
Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the

• A. lack of qualified providers in provider networks
• B. lack of resources necessary to establish case management programs for patients with complex conditions
• C. unstable eligibility status of Medicaid recipients
• D. inability of Medicaid recipients to change health plans or PCPs

Answer: C

NEW QUESTION 7
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say

• A. that the construction of a data warehouse is quick and simple
• B. that a data warehouse addresses the problems associated with multiple data management systems
• C. that a data warehouse stores only current data
• D. all of the above

Answer: B

NEW QUESTION 8
In order to achieve changes in outcomes, health plans make changes to existing structures and processes. The introduction of preauthorization as an attempt to control overuse of services is an example of a reactive change. Reactive changes are typically

• A. both planned and controlled
• B. planned, but they are rarely controlled
• C. controlled, but they are rarely planned
• D. neither planned nor controlled

Answer: C

NEW QUESTION 9
Determine whether the following statement is true or false:
All health plans participating in the Federal Employee Health Benefits Program (FEHBP) are required to use the Consumer Assessment of Health Plans (CAHPS) to measure customer satisfaction.

• A. True
• B. False

Answer: A

NEW QUESTION 10
Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.
If Ms. Stanley agrees to the generic substitution, she will receive a drug that

• A. has not been tested for safety and efficacy in large clinical trials
• B. is available without a prescription at a reasonable cost
• C. has been classified by the Food and Drug Administration (FDA) as safe, but that has not been proven fully effective
• D. contains active ingredients that are identical to those of the prescribed brand-name drug

Answer: D

NEW QUESTION 11
Many health plans use HRA to target their preventive care programs to the healthcare needs of their members. With regard to HRA, it is correct to say that

• A. Health plans rarely delegate HRA activities to external entities
• B. Health plans typically focus their HRA efforts on newly enrolled members
• C. HRA focuses on clinical data for an entire population and does not include demographic information that might identify individual members
• D. HRA is generally a reliable predictor of medical resource utilization

Answer: B

NEW QUESTION 12
In order for a health plan’s performance-based quality improvement programs to be effective, the desired outcomes must be

• A. achievable within a specified timeframe
• B. defined in terms of multiple results
• C. expressed in subjective, qualitative terms
• D. all of the above

Answer: A

NEW QUESTION 13
The following statement(s) can correctly be made about the scope of case management:
* 1. Case management incorporates activities that may fall outside a health plan’s typical responsibilities, such as assessing a member’s financial situation
* 2. Case management generally requires a less comprehensive and complex approach to a course of care than does utilization review
* 3. Case management is currently applicable only to medical conditions that require inpatient hospital care and are categorized as catastrophic in terms of health and/or costs

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

Answer: D

NEW QUESTION 14
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
In most commercial health plans, the case management process is directed by a case manager whose responsibilities typically include

• A. focusing on a disabled member’s vocational rehabilitation and training
• B. approving all care decisions for patients under case management
• C. reducing the fragmentation of care that often results when individuals obtain services from several different providers
• D. all of the above

Answer: C

NEW QUESTION 15
The Riverside Health Plan is considering the following provider compensation options to use in its contracts with several provider groups and hospitals:
* 1. A discounted fee-for-service (DFFS) payment system
* 2. A case rate system
* 3. Capitation
If Riverside wants to use only those compensation methods that encourage the efficient use of resources, then the compensation method(s) that Riverside should consider for its new contracts include

• A. 1, 2, and 3
• B. 1 and 2 only
• C. 2 and 3 only
• D. 3 only

Answer: C

NEW QUESTION 16
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 17
Private employers are key purchasers of health plan services. The following statement(s) can correctly be made about employer expectations about the quality and cost- effectiveness of healthcare services:
* 1. For both health maintenance organizations (HMOs) and non-HMO plans, employers typically have access to accreditation results and performance measurement reports to help them evaluate the quality of healthcare and service
* 2. Because of employers’ concern about the quality and costs of healthcare services available through health plans, direct contracting has become a dominant model among employers who sponsor health benefit programs for their employees

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

Answer: D

NEW QUESTION 18
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 19
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