All About Approved AHM-530 Prep

NEW QUESTION 1

Federal laws—including the Ethics in Patient Referrals Act, the Health Maintenance Organization (HMO) Act of 1973, the Employee Retirement Income Security Act (ERISA), and the Federal Trade Commission Act—have impacted the ways that health plans conduct business. For instance, the Mosaic Health Plan must comply with the following federal laws in order to operate:
Regulation 1: Mosaic must establish a mandated grievance resolution mechanism, including a method for members to address grievances with network providers.
Regulation 2: Mosaic must not allow its providers to refer Medicare and Medicaid patients to entities in which they have a financial or ownership interest.
From the answer choices below, select the response that correctly identifies the federal legislation on which Regulation 1 and Regulation 2 are based.

• A. Regulation 1 - The Ethics in Patient Referrals Act Regulation 2 - The HMO Act of 1973
• B. Regulation 1 - The HMO Act of 1973 Regulation 2 - The Ethics in Patient Referrals Act
• C. Regulation 1 - ERISA Regulation 2 - The Federal Trade Commission Act
• D. Regulation 1 - The Federal Trade Commission Act Regulation 2 - ERISA

Answer: B

NEW QUESTION 2

A population’s demographic factors—such as income levels, age, gender, race, and ethnicity—can influence the design of provider networks serving that population. With respect to these demographic factors, it is correct to say that

• A. higher-income populations have a higher incidence of chronic illnesses than do lowerincome populations
• B. compared to other groups, young men are more likely to be attached to particular providers
• C. a population with a high proportion of women typically requires more providers than does a population that is predominantly male
• D. Health plans should not recognize, in either the design of networks or the evaluation of provider performance, racial and ethnic differences in the member population

Answer: C

NEW QUESTION 3

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:

• A. D
• B. Enberg's young patients receive appropriate immunizations at the right ages
• C. D
• D. Enberg conforms to standards for prescribing controlled substances
• E. The condition of one of D
• F. Enberg's patients improved after the patient received medical treatment from D
• G. Enberg
• H. D
• I. Enberg's procedures are adequate for ensuring patients' access to medical care

Answer: A

NEW QUESTION 4

The following statement(s) can correctly be made about the TRICARE managed healthcare program of the U.S. Department of Defense.
* 1. Active-duty military personnel are automatically enrolled in TRICARE’s HMO option (TRICARE Prime).
* 2. Eligible family members and dependents can enroll in TRICARE Prime, the PPO plan (TRICARE Extra), or an indemnity plan (TRICARE Standard).

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

Answer: A

NEW QUESTION 5

The Pine Health Plan has incorporated pharmacy benefits management into its operations to form a unified benefit. Potential advantages that Pine can receive from this action include:

• A. the fact that unified benefits improve the quality of patient care and the value of pharmacy services to Pine's plan members
• B. the fact that control over the formulary and network contracting can give Pine control over patient access to prescription drugs and to pharmacies
• C. the fact that managing pharmacy benefits in-house gives Pine a better chance to meet customer needs by integrating pharmacy services into the plan's total benefits package
• D. all of the above

Answer: D

NEW QUESTION 6

The Holiday Health Plan is preparing to enter a new market. In order to determine the optimal size of its provider panel in the new market, Holiday is conducting a competitive analysis of provider networks of the market’s existing health plans. Consider whether, in conducting its competitive analysis, Holiday should seek answers to the following questions:
Question 1: What are the cost-containment strategies of the health plans with increasing market shares?
Question 2: What are the premium strategies of the health plans with large market shares?
Question 3: What are the characteristics of health plans that are losing market share?
In its competitive analysis, Holiday should most likely obtain answers to questions

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

Answer: A

NEW QUESTION 7

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.
One statement that can correctly be made about Gardenia’s two-level POS product is that

• A. members who self-refer without first seeing their PCPs will receive no benefits
• B. both Gardenia and the PCPs stand to benefit if the non-provider panels are kept relatively narrow
• C. members will pay higher coinsurance or copayments if they first see their PCPs each time
• D. the plan offers no financial incentives to members to choose an in-network specialist over a non-network specialist

Answer: D

NEW QUESTION 8

The Aegean Health Plan delegated its utilization management (UM) program to the Silhouette IPA. Silhouette, in turn, transferred authority for case management to Brandon Health Services. In this situation, Brandon is best described as the

• A. delegator, and Aegean is ultimately responsible for Brandon’s performance
• B. delegator, and Silhouette is ultimately responsible for Brandon’s performance
• C. subdelegate, and Aegean is ultimately responsible for Brandon’s performance
• D. subdelegate, and Silhouette is ultimately responsible for Brandon’s performance

Answer: C

NEW QUESTION 9

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 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

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service
(DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:

• A. D
• B. Enberg's young patients receive appropriate immunizations at the right ages
• C. D
• D. Enberg's young patients receive appropriate immunizations at the right ages
• E. The condition of one of D
• F. Enberg's patients improved after the patient received medical treatment from D
• G. Enberg
• H. D
• I. Enberg's procedures are adequate for ensuring patients' access to medical care

Answer: A

NEW QUESTION 12

The Sweeney Health Plan uses the discounted fee-for-service (DFFS) method to compensate some of its providers. Under this method of compensation, Sweeney calculates payments based on

• A. The standard fees of indemnity health insurance plans, adjusted by region
• B. The Medicare fee schedules used by other health plans, adjusted by region
• C. Whichever amount is higher, the billed charge or the DFFS amount
• D. Whichever amount is lower, the billed charge or the DFFS amount

Answer: D

NEW QUESTION 13

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 14

The NPDB specifies the entities that are eligible to request information from the data bank, as well as the conditions under which requests are allowed. In general, entities that are eligible to request information from the NPDB include

• A. medical malpractice insurers and the general public
• B. medical malpractice insurers and professional societies that are screening applicants for membership
• C. the general public and state licensing boards
• D. state licensing boards and professional societies that are screening applicants for membership

Answer: D

NEW QUESTION 15

The Edgewood Health Plan uses a combination of structural, process, outcomes, and customer satisfaction measures to evaluate its network providers’ performance. Edgewood would correctly use outcomes measures to evaluate a provider’s

• A. Compliance with specific regulatory or accrediting requirement
• B. Appropriate use of specified procedures
• C. Patient progress following treatment
• D. Patient perceptions about how well the provider addresses medical problems

Answer: C

NEW QUESTION 16

The following statements are about incentive programs used for providers. Select the answer choice containing the correct statement.

• A. Risk pools based on aggregate provider performance eliminate problems associated with “free riders.”
• B. A hospital bonus pool is usually split between the health plan and the PCPs.
• C. Bonus pools based on the performance of specific providers are usually easier to administer than those based on the performance of the plan as a whole.
• D. For providers, withhold arrangements eliminate the risk of losing base income.

Answer: B

NEW QUESTION 17

One reimbursement method that health plans can use for hospitals is the ambulatory payment classifications (APCs) method. APCs bear a resemblance to the diagnosis-related groups (DRGs) method of reimbursement. However, when comparing APCs and DRGs, one of the primary differences between the two methods is that only the APC method

• A. is typically used for outpatient care
• B. assigns a single code for treatment
• C. applies to treatment received during an entire hospital stay
• D. is considered to be a retrospective payment system

Answer: A

NEW QUESTION 18

One difference between a fee-for-service (FFS) reimbursement arrangement and capitation is that the FFS arrangement:

• A. Is a prospective payment system, whereas capitation is a retrospective payment system
• B. Has a potential to induce providers to underutilize medical resources, whereas capitation does not have this potential disadvantage
• C. Bases the amount of reimbursement on the actual medical services delivered, whereas reimbursement under capitation is independent of the actual volume and cost of services provided
• D. Is most often used by health plans to reimburse healthcare facilities, whereas capitation is most often used by health plans to reimburse specialty care providers

Answer: C

NEW QUESTION 19

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 20

A provider group purchased from an insurer individual stop-loss coverage for primary and specialty care services with an $8,000 attachment point and 10% coinsurance. If the group's accrued cost for the primary and specialty care treatment of one patient is $10,000, then the amount that the insurer would be responsible for reimbursing the provider group for these costs is:

• A. $200
• B. $1,000
• C. $1,800
• D. $9,000

Answer: C

NEW QUESTION 21
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