All About Actual AHM-530 Free Practice Exam

NEW QUESTION 1

The provider contract that Dr. Ted Dionne has with the Optimal Health Plan includes an arrangement that requires Dr. Dionne to notify Optimal if he contracts with another health plan at a rate that is lower than the rate offered to Optimal. Dr. Dionne must also offer this lower rate to Optimal. This information indicates that the provider contract includes a:

• A. Most-favored-nation arrangement
• B. Warranty arrangement
• C. Locum tenens arrangement
• D. Nesting arrangement

Answer: A

NEW QUESTION 2

Lakesha Frazier, a member of a health plan in a rural area, had been experiencing heart palpitations and shortness of breath. Ms. Frazier’s primary care provider (PCP) referred her to a local hospital for an electrocardiogram. The results of the electrocardiogram were transmitted for diagnosis via high-speed data transmission to a heart specialist in a city 500 miles away. This information indicates that the results of Ms. Frazier’s electrocardiogram were transmitted using a communications system known as

• A. Anarrow network
• B. An integrated healthcare delivery system
• C. Telemedicine
• D. Customized networking

Answer: C

NEW QUESTION 3

Health plans are required to follow several regulations and guidelines regarding the access and adequacy of their provider networks. The Federal Employee Health Benefits Program (FEHBP) regulations, for example, require that health plans

• A. Allow members direct access to OB/GYN services
• B. Allow members direct access to prescription drug services
• C. Provide access to Title X family-planning clinics
• D. Provide average office waiting times of no more than 30 minutes for appointments with plan providers

Answer: D

NEW QUESTION 4

If a member of the Green Health Plan reasonably believes that a provider in Green's provider network was acting as Green's employee or agent while providing negligent care, then the member may have cause to bring action against the health plan. This legal concept is known as vicarious liability. Steps that Green can take to reduce its exposure to vicarious liability claims include:

• A. Placing restrictions on provider-member communication involving treatment decisions.
• B. Implementing risk management and quality assurance programs for its provider network.
• C. Including in its provider agreements and marketing and membership literature a statement that members of the Green provider network are not independent contractors.
• D. All of the above.

Answer: B

NEW QUESTION 5

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 6

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 7

The following statements are about the negotiation process of provider contracting. Three of the statements are true and one of the statements is false. Select the answer choice containing the FALSE statement.

• A. While preparing for negotiations, the health plan usually sends the provider an application to join the provider network, a list of credentialing requirements, and a copy of the proposed provider contract, which may or may not include the proposed reimbursement schedule.
• B. In general, the ideal negotiating style for provider contracting is a collaborative approach.
• C. Typically, the health plan and the provider negotiate the reimbursement arrangement between the parties before they negotiate the scope of services and the contract language.
• D. The actual signing of the provider contract typically takes place after negotiations are completed.

Answer: C

NEW QUESTION 8

Dr. Michelle Kubiak has contracted with the Gem Health Plan, a Medicare+Choice health plan, to provide medical services to Gem's enrollees. Gem pays Dr. Kubiak $40 per enrollee per month for providing primary care. Gem also pays her an additional $10 per enrollee per month if the cost of referral services falls below a targeted level. This information indicates that, according to the substantial financial risk formula, Dr. Kubiak's referral risk under this contract is equal to:

• A. 20%, and therefore this arrangement puts her at substantial financial risk
• B. 20%, and therefore this arrangement does not put her at substantial financial risk
• C. 25%, and therefore this arrangement puts her at substantial financial risk
• D. 25%, and therefore this arrangement does not put her at substantial financial risk

Answer: B

NEW QUESTION 9

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 10

Health plans use a variety of sources to find candidates to recruit for their provider networks. In general, two of the most effective methods of finding candidates are through

• A. Word of mouth and on-site training programs
• B. Word of mouth and direct mail
• C. Advertisements in local newspapers and on-site training programs
• D. Advertisements in local newspapers and direct mail

Answer: B

NEW QUESTION 11

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.
A formulary lists the drugs and treatment protocols that are considered to be the preferred
therapy for a given managed population. The Fairfax Health Plan uses the type of formulary which covers drugs that are on its preferred list as well as drugs that are not on its preferred list. This information indicates that Fairfax uses the (closed / open) formulary method. In using the formulary approach to pharmacy benefits management, Fairfax most likely experiences (higher / lower) costs for its members’ prescription drugs than it would if it did not use a formulary.

• A. closed / higher
• B. closed / lower
• C. open / higher
• D. open / lower

Answer: D

NEW QUESTION 12

The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.
The per diem reimbursement method will require Gladspell to pay Ellysium a

• A. Fixed rate for each day a plan member is treated in Ellysium’s subacute care facility
• B. Discounted charge for all subacute care services given by Ellysium
• C. Rate that varies depending on patient category
• D. Fixed rate per enrollee per month

Answer: A

NEW QUESTION 13

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 14

The Ventnor Health Plan requires the physicians in its provider network to be board certified. Ventnor has received requests to become a part of the network from the following specialists:
Cheryl Stovall, who is currently in the process of completing a residency in her field ofspecialization.
Thomas Kalil, who has completed a residency in his field of specialization and has passed a qualifying examination in that field within two years of completing his residency.
Roger Todd, who has completed a residency in his field of specialization but has not passed a qualifying examination in that field.
Ventnor's requirement of board certification is met by:

• A. Cheryl Stovall, Thomas Kalil, and Roger Todd.
• B. Thomas Kalil and Roger Todd only.
• C. Thomas Kalil only.
• D. None of these individuals.

Answer: C

NEW QUESTION 15

After HIPAA was enacted, Congress amended the law to include the Mental Health Parity Act (MHPA) of 1996, a federal requirement relating to mental health benefits. One true statement about the MHPA is that it

• A. requires all health plans to provide coverage for mental health services
• B. requires health plans to carve out mental/behavioral healthcare from other services provided by the plans
• C. allows health plans to require patients receiving mental health services to pay higher copayments than patients seeking treatment for physical illnesses
• D. prohibits health plans that offer mental health benefits from applying more restrictive limits on coverage for mental illness than on coverage for physical illness

Answer: D

NEW QUESTION 16

The following statements are about the responsibilities that providers are expected to assume under most provider contracts with health plans. Select the answer choice containing the correct statement.

• A. All health plans now include in their provider contracts a statement that explicitly places responsibility for the medical care of plan members on the health plan rather than on the provider.
• B. According to the wording of most provider contracts, the responsibility of providers to deliver medical services to a plan member is not contingent upon the provider’s receipt of information regarding the member’s eligibility for these services.
• C. Most health plans include in their provider contracts a clause which requires providers to maintain open communication with plan members regarding appropriate treatment plans, even if the services are not covered by the member’s health plan.
• D. Most provider contracts require participating providers to discuss health plan payment arrangements with patients who are covered by the plan.

Answer: C

NEW QUESTION 17

Although a health plan is allowed to delegate many activities to outside sources, the National Committee for Quality Assurance (NCQA) has determined that some activities are not delegable.
These activities include

• A. evaluation of new medical technologies
• B. overseeing delegated medical records activities
• C. developing written statements of members’ rights and responsibilities
• D. all of the above

Answer: D

NEW QUESTION 18

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. A credentials verification organization (CVO) can be certified to verify certain pertinent credentialing information, including

• A. Liability claims histories of prospective providers
• B. Hospital privileges of prospective providers
• C. Malpractice insurance on prospective providers
• D. All of the above

Answer: D

NEW QUESTION 19

Promise, Inc., a corporation that specializes in cancer services, employs its physicians and support staff and provides facilities and ancillary services for cancer patients. Promise has contracted with the Cordelia Health Plan to provide all specialty services for Cordelia plan members who are undergoing cancer treatment. In return, Promise receives a capitated amount from Cordelia. Promise is an example of a type of specialty services organization known as a

• A. Specialty IPA
• B. Disease management company
• C. Single specialty management specialist
• D. Specialty network management company

Answer: B

NEW QUESTION 20

The following statements can correctly be made about the advantages and disadvantages to an health plan of using the various delivery options for pharmacy services.

• A. A disadvantage of using open pharmacy networks is that the health plan’s control over costs is limited to setting reimbursement levels.
• B. An advantage of using performance-based systems is that they tend to increase participation in the health plan’s pharmacy network.
• C. A disadvantage of using customized pharmacy networks is that these networks typically can be implemented only in companies with fewer than 500 employees.
• D. All of these statements are correct.

Answer: A

NEW QUESTION 21
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