Avant-garde AHM-250 Guidance 2021

NEW QUESTION 1

One way that MCOs involve providers in risk sharing is by retaining a percentage of the providers' payment during a plan year. At the end of the plan year, the MCO may use the amount retained to offset or pay for any cost overruns for referral or hospital

• A. withholds
• B. usual, customary, and reasonable (UCR) fees
• C. risk pools
• D. per diems

Answer: A

NEW QUESTION 2

Patrick Flaherty's employer has contracted to receive healthcare for its employees from the Abundant Healthcare System. Mr. Flaherty visits his primary care physician (PCP), who sends him to have some blood tests. The PCP then refers Mr. Flaherty to a special

• A. an integrated delivery system (IDS)
• B. a Management Services Organization (MSO)
• C. a Physician Practice Management (PPM) company
• D. a physician-hospital organization (PHO)

Answer: A

NEW QUESTION 3

The data evaluation stage of utilization review (UR) includes both administrative reviews and medical reviews. One true statement about these types of reviews is that:

• A. An administrative review must be conducted by a health plan staff member who is a medical professional.
• B. The primary purpose of an administrative review is to evaluate the appropriateness of a proposed medical service.
• C. UR staff members typically conduct a medical review of a proposed medical service before they conduct an administrative review for that same service.
• D. One purpose of a medical review is to evaluate the medical necessity of a proposed medical service.

Answer: D

NEW QUESTION 4

The Madison Health Plan, a national MCO, and a local hospital system that operates its own managed healthcare network recently created a new and separate managed healthcare organization, the Pineapple Health Plan. Madison and the hospital system share own

• A. a consolidation
• B. a joint venture
• C. a merger
• D. an acquisition

Answer: B

NEW QUESTION 5

An HMO’s quality assurance program must include

• A. A statement of the HMO’s goals and objectives for evaluating and improving enrollees’ health status
• B. Documentation of all quality assurance activities
• C. System for periodically reporting program results to the HMO’s board of directors, its providers, and regulators
• D. All the above

Answer: D

NEW QUESTION 6

The health plan determines what it considers to be the acceptable fee for a service or procedure and the physician agrees to accept that amount as payment in full for the procedure

• A. Usual, Customary, and Reasonable fee
• B. Discounted FFS
• C. Fee Maximum
• D. Relative Value Scale

Answer: B

NEW QUESTION 7

The National Association of Insurance Commissioners (NAIC) developed the Small Group Model Act to enable small groups to obtain accessible, yet affordable, group health benefits. The model law limits the rate spread, which is the difference between the highest and lowest rates that a health plan charges small groups, to a particular ratio.
According to the Model Act, for example, if the lowest rate an HMO charges a small group for a given set of medical benefits is $40, then the maximum rate the HMO can charge for the same set of benefits is

• A. $60
• B. $80
• C. $120
• D. $160

Answer: B

NEW QUESTION 8

Combined system of preventive, diagnostic and therapeutic measures that focuses on management of specific chronic illness or medical conditions are:

• A. Utilization Review
• B. Case Management
• C. Demand Management
• D. Disease management

Answer: B

NEW QUESTION 9

The following statements apply to health reimbursement arrangements. Select the answer choice that contains the correct statement.

• A. Only employers are permitted to establish and fund HRAs.
• B. The popularity of HRAs waned following a 2002 ruling by U.
• C. Treasury Department regarding their treatment in the tax code.
• D. HRAs must be offered in conjunction with a high-deductible health plan.
• E. The guaranteed portability feature of HRAs has contributed to their popularity.

Answer: A

NEW QUESTION 10

Before an HMO contracts with a physician, the HMO first verifies the physician's credentials.
Upon becoming part of the HMO's organized system of healthcare, the physician is typically subject to

• A. both recredentialing and peer review
• B. recredentialing only
• C. peer review only
• D. neither recredentialing nor peer review

Answer: C

NEW QUESTION 11

Paul Gilbert has been covered by a group health plan for two years. He has been undergoing treatment for angina for the past three months. Last week, Mr. Gilbert began a new job and immediately enrolled in his new company's group health plan, which has a

• A. Can exclude coverage for treatment of M
• B. Gilbert's angina for one year, because HIPAA does not impact a group health plan's pre-existing condition provision.
• C. Can exclude coverage for treatment of M
• D. Gilbert's angina for one year, because M
• E. Gilbert did not have at least 36 months of creditable coverage under his previous health plan.
• F. Can exclude coverage for treatment of M
• G. Gilbert's angina for three months, because that is the length of time he received treatment for this medical condition prior to his enrollment in the new health plan.
• H. Cannot exclude his angina as a pre-existing condition, because the one-year pre- existing condition provision is offset by at least one year of continuous coverage under his previous health plan.

Answer: D

NEW QUESTION 12

Which of the following population groups are eligible for Medicare coverage

• A. Individuals aged 65 & above, regardless of income & medical history
• B. Individuals suffering from end stage renal disease, regardless of age
• C. Individuals aged 50 or above suffering from qualifying disabilities
• D. Both A & B

Answer: D

NEW QUESTION 13

Marlee Whitcomb was covered as a dependent under the group health plan provided by her father's employer. That health plan complied with the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986. When Ms. Whitcomb married, she c

• A. can continue her group coverage for a period not to exceed 48 months
• B. can continue her group coverage for a period not to exceed 36 months
• C. cannot continue her group coverage, but has the right to convert the group coverage to an individual health plan
• D. can continue her group coverage indefinitely

Answer: B

NEW QUESTION 14

Two MCOs in a single service area divided purchasers into two groups and agreed to each market their products to only one purchaser group. This information indicates that these two MCOs violated antitrust requirements because they engaged in an activity k

• A. horizontal group boycott
• B. horizontal division of markets
• C. a tying arrangement
• D. price fixing

Answer: B

NEW QUESTION 15

The following statements apply to enrollment statistics for HSAs. Select the answer choice that contains the CORRECT statement.

• A. HSAs have helped expand health care coverage to consumers who were previously uninsured.
• B. The vast majority of enrollees in HSA health plans are wealthy.
• C. Most people receiving coverage through HSA health plans are individuals rather than families.
• D. HSAs appeal primarily to young consumers.

Answer: A

NEW QUESTION 16

Several marketplace factors helped fuel the movement toward consumer choice. Which one of the following statements is NOT accurate with regard to these factors?

• A. After a period of relative stability, annual growth in private health spending per capita began to increase rapidly in 2002.
• B. During the height of the recent cost upswing, insurance premiums were increasing by more than 13% annually.
• C. Increased utilization was the largest factor contributing to the rise in premiums, accounting for 43% of the increase.
• D. Employer payers began seeking ways to control spiraling utilization rates and provide lower cost health coverage options.

Answer: A

NEW QUESTION 17

The following statements are about federal laws that affect healthcare organizations. Select the answer choice containing the correct response.

• A. The Women's Health and Cancer Rights Act (WHCRA) of 1998 requires health plans to offer mastectomy benefits.
• B. The Health Care Quality Improvement Act (HCQIA) requires hospitals, group practices, and HMOs to comply with all standard antitrust legislation, even if these entities adhere to due process standards that are outlined in HCQIA.
• C. The Newborns' and Mothers' Health Protection Act (NMHPA) of 1996 mandates that coverage for hospital stays for childbirth must generally be a minimum of 24 hours for normal deliveries and 48 hours for cesarean births.
• D. Although the Mental Health Parity Act (MHPA) does not require health plans to offer mental health coverage, it imposes requirements on those plans that do offer mental health benefits.

Answer: D

NEW QUESTION 18

Katrina Lopez is a claims analyst for a health plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Ms. Lopez reviewed a health claim for answers to the following questions:
Question A -

• A. A, B, C, and D
• B. A, B, and D only
• C. B, C, and D only
• D. A and C only

Answer: A

NEW QUESTION 19

In the CPT system, each service or procedure is identified by

• A. Three-digit with decimal point
• B. Three-digit
• C. Five-digit with decimal point
• D. Five-digit

Answer: D

NEW QUESTION 20

One true statement regarding ethics and laws is that the values of a community are reflected in

• A. both ethics and laws, and both ethics and laws are enforceable in the court system
• B. both ethics and laws, but only laws are enforceable in the court system
• C. ethics only, but only laws are enforceable in the court system
• D. laws only, but both ethics and laws are enforceable in the court system

Answer: B

NEW QUESTION 21

Who will be covered by TRICARE PRIME by applying for enrollment

• A. Active duty military personnel
• B. Active duty Dependents
• C. Retires
• D. B and C

Answer: D

NEW QUESTION 22

To address the problems associated with multiple data management systems, the Kayak Health Plan has begun to use a data warehouse. One likely characteristic of Kayak's data warehouse is that:

• A. It requires Kayak's individual databases to store large amounts of data that are not needed for daily operations.
• B. It contains data from internal sources only.
• C. It stores historical data rather than current data.
• D. The data in the warehouse are linked by a common subject.

Answer: D

NEW QUESTION 23

One factor the Sandpiper Health Plan uses to assess its quality is a clinician's bedside manner, i.e., how friendly and understanding the clinician is, whether the patient feels that the clinician listens to the patient's concerns, how well the clinical

• A. a provider service quality issue
• B. an administrative service quality issue a healthcare process quality issue
• C. a healthcare outcomes quality issue
• D. a healthcare process quality issue

Answer: A

NEW QUESTION 24

The Mirror Health Plan uses a form of computer/telephony integration (CTI) to manage telephone calls coming into its member services department. When a member calls the plan's central telephone number, a device answers the call with a recorded message and

• A. a member outreach program
• B. a complaint resolution procedure (CRP)
• C. an automatic call distributor (ACD)
• D. an interactive voice response (IVR) system

Answer: C

NEW QUESTION 25

Health plans use the following to determine the number of providers to add to a network:

• A. Staffing ratios
• B. Drive time
• C. Geographic availability
• D. All of the above

Answer: D

NEW QUESTION 26
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