Abreast Of The Times Network Management AHM-530 Actual Exam

NEW QUESTION 1

Health plans typically conduct two types of reviews of a provider's medical records: an evaluation of the provider's medical record keeping (MRK) practices and a medical record review (MRR). One true statement about these types of reviews is that:

• A. An MRK covers the content of specific patient records of a provider.
• B. The NCQA requires an examination of MRK with all of a health plan's office evaluations.
• C. An MRR includes a review of the policies, procedures, and documentation standards the provider follows to create and maintain medical records.
• D. The NCQA requires MRR for both credentialing and recredentialing of providers in a health plan's network.

Answer: A

NEW QUESTION 2

Before or during the orientation process, health plans generally provide new network providers with a provider manual. One of the primary purposes of the provider manual is to

• A. Provide a directory of contracted providers
• B. Help providers and their staffs develop methods of improving the operation of their practices
• C. Provide feedback to providers regarding their performance
• D. Reinforce and document contractual provisions

Answer: D

NEW QUESTION 3

The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
The comparative method of evaluation that Azure uses to identify and implement the practices that lead to the best outcomes is known as

• A. Case mix analysis
• B. Outcomes research
• C. Benchmarking
• D. Provider profiling

Answer: C

NEW QUESTION 4

An health plan’s contract negotiation team consists of several skilled individuals from different areas. At least one of the members is responsible for evaluating the wording of specific clauses to ensure that the health plan’s rights are protected, as well as to ensure that the contract is in compliance with state and federal regulation. By profession, this member of the contract negotiation team is typically

• A. Amedical director
• B. An attorney
• C. Afinancial manager
• D. Aclaims manager

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

From the following answer choices, choose the type of clause or provision described in this situation.
The Aviary Health Plan includes in its provider contracts a clause or provision that places the ultimate responsibility for an Aviary plan member’s medical care on the provider.

• A. Cure provision
• B. Hold-harmless provision
• C. Evergreen clause
• D. Exculpation clause

Answer: D

NEW QUESTION 7

The Medicaid program subsidizes indigent care through payments to disproportionate share hospitals (DSHs). The Preamble Hospital is a DSH. As a DSH, Preamble most likely:

• A. Receives financial assistance from the federal government but not a state government.
• B. Is at a higher risk of operating at a loss than are most other hospitals.
• C. Receives no payments directly from Medicaid for services rendered but rather receives a portion of the capitation payment that Medicaid makes to the health plans with which Preamble contracts.
• D. Is eligible for capitation rates that are significantly higher than the FFS average for all covered Medicaid services.

Answer: B

NEW QUESTION 8

Participating providers in a health plan’s network must undergo recredentialing on a regular basis. During recredentialing, a health plan typically reviews

• A. a provider’s current, updated application information, as well as provider’s peer reviews and performance reports on the provider
• B. a provider’s current, updated application information, as well as the provider’s education and prior work history
• C. a provider’s education and prior work history only
• D. peer reviews and performance reports on a provider and the provider’s prior work history only

Answer: A

NEW QUESTION 9

One true statement about the responsibilities of providers under typical provider contracts is that most provider contracts:

• A. include a clause which states that providers must maintain open communications with patients regarding appropriate treatment plans, unless the services are not covered by the member's health plan
• B. hold that the responsibility of the provider to deliver services is usually subject to theprovider's receipt of information regarding the eligibility of the member
• C. contain a gag clause or a gag rule
• D. include a clause that explicitly places the responsibility for medical care on the health plan rather than on the provider of medical services

Answer: B

NEW QUESTION 10

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.
The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan member for covered services is known as:

• A. Atermination with cause clause
• B. Ahold-harmless clause
• C. An indemnification clause
• D. Acorrective action clause

Answer: B

NEW QUESTION 11

Some jurisdictions have enacted corporate practice of medicine laws. One effect that corporate practice of medicine laws have had on HMO provider networks is that these laws typically

• A. require incorporated HMOs to practice medicine through licensed employees
• B. require HMOs to form exclusive contracts with physician groups who agree to dedicate all or most of their practices to HMO patients in return for a set payment or revenue-sharing
• C. restrict the ability of staff model HMOs to hire physicians directly, unless the physiciansown the HMO
• D. encourage incorporated HMOs to obtain profits from their provisions of physician professional services

Answer: C

NEW QUESTION 12

One true statement about the compensation arrangement known as the case rate system is that, under this system,

• A. Providers stand to gain or lose based on the number and types of treatments used for each case
• B. Providers have no incentives to take an active role in managing cost and utilization
• C. Payors cannot adjust standard case rates to reflect the severity of the patient’s condition or complications that arise from multiple medical problems
• D. Payors have the opportunity to benefit from the provider’s cost savings

Answer: A

NEW QUESTION 13

Health plans can often reduce workers’ compensation costs by incorporating 24-hour coverage into their workers’ compensations programs. Twenty-four-hour coverage reduces costs by

• A. Maximizing the effects of cost shifting
• B. Eliminating the need for utilization management
• C. Requiring members to use separate points of entry for job-related and non-job related services
• D. Combining administrative services for workers’ compensation and non-workers’ compensation healthcare and disability coverage

Answer: D

NEW QUESTION 14

The Omnibus Budget Reconciliation Act of 1986 (OBRA 1986) established the Programs of All-Inclusive Care for the Elderly (PACE). One characteristic of the PACE programs is that:

• A. They are available to United States citizens only after they reach age 65.
• B. They have an upper dollar limit.
• C. They receive a monthly capitation that is set at 100% of the Adjusted Average Per Capita Cost (AAPCC).
• D. PACE providers receive capitated payments only through the PACE agreement.

Answer: D

NEW QUESTION 15

The provider contract that Dr. Huang Kwan has with the Poplar Health Plan includes a typical scope of services provision. The medical service that Dr. Kwan provided to Alice Meyer, a Poplar plan member, is included in the scope of services. The following statement(s) can correctly be made about this particular medical service:

• A. D
• B. Kwan most likely was required to seek authorization from Poplar before performing this particular service.
• C. D
• D. Kwan most likely was paid on a FFS basis for providing this service.
• E. Both A and B
• F. A only
• G. B only
• H. Neither A nor B

Answer: D

NEW QUESTION 16

In open panel contracting, there are several types of delivery systems. One such delivery system is the faculty practice plan (FPP). One likely result that a health plan will experience by contracting with an FPP is that the health plan will

• A. be able to select most of the physicians in the FPP
• B. achieve the highest level of cost effectiveness possible
• C. experience limited control over utilization
• D. achieve the most effective case management possible

Answer: C

NEW QUESTION 17

The following statement(s) can correctly be made about hospitalists.
* 1. The hospitalist’s main function is to coordinate diagnostic and treatment activities to ensure that the patient receives appropriate care while in the hospital.
* 2. The hospitalist’s role clearly supports the health plan concept of disease management.

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

Answer: B

NEW QUESTION 18

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.
If the Ellysium subacute care unit is typical of most hospital-based subacute skilled nursing units, then this unit could be used for patients who no longer need to be in the hospital’s acute care unit but who still require

• A. Daily medical care and monitoring
• B. Regular rehabilitative therapy
• C. Respiratory therapy
• D. All of the above

Answer: D

NEW QUESTION 19

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 20

The Ionic Group, a provider group with 10,000 plan members, purchased for its hospital risk pool aggregate stop-loss insurance with a threshold of 110% of projected costs and a 10% coinsurance provision. Ionic funds the hospital risk pool at $40 per member per month (PMPM).
If Ionic’s actual hospital costs are $5,580,000 for the year, then, under the aggregate stop- loss agreement, the stop-loss insurer is responsible for reimbursing Ionic in the amount of

• A. $30,000
• B. $270,000
• C. $300,000
• D. $702,000

Answer: B

NEW QUESTION 21
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