Top Tips Of Improve AHM-540 Testing Software

NEW QUESTION 1
PBMs are accredited by the same organizations that accredit health plans.

• A. True
• B. False

Answer: B

NEW QUESTION 2
Determine whether the following statement is true or false:
The key to successfully managing the quality and cost-effectiveness of healthcare services for Medicaid enrollees is to merge Medicaid recipients into existing plans.

• A. True
• B. False

Answer: B

NEW QUESTION 3
Benchmarking is a quality improvement strategy used by some health plans. With regard to benchmarking, it is correct to say that

• A. cost-based benchmarking reveals why some areas of a health plan perform better or worse than comparable areas of other organizations
• B. diagnosis-related groups (DRGs) are a source of benchmarking data that describe individual procedures and cover both inpatient and outpatient care
• C. patient billing records provide a much more accurate account of procedure costs for benchmarking than do current procedural terminology (CPT) codes
• D. the focus of benchmarking for health plan has shifted from identifying the lowest cost practices to identifying best practices

Answer: D

NEW QUESTION 4
Drugs included in a health plan’s formulary can be classified according to how freely they can be prescribed. By definition, a drug that requires some sort of review or approval by a plan physician or group of physicians before the prescription can be filled is

• A. an unrestricted drug
• B. a monitored drug
• C. a restricted drug
• D. a conditional drug

Answer: B

NEW QUESTION 5
The case management program director at the Nova Health Plan calculated the program’s ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:
Administrative costs for case management ..........$40,000
Actual medical care expenses for patients under case management ..........$680,000
Projected medical care expenses for the same patients without case management
..........$900,000
This information indicates that, for the previous quarter, Nova’s ratio of medical expense savings to case management administrative costs was

• A. 0.71/1
• B. 0.80/1
• C. 5.50/1
• D. 1.25/1

Answer: C

NEW QUESTION 6
Medicare beneficiaries can obtain healthcare benefits through fee-for-service (FFS) Medicare programs, Medicare medical savings account (MSA) plans, Medigap insurance, or coordinated care plans (CCPs). Unlike other coverage options, CCPs

• A. provide only those benefits covered by Medicare Part A and Part B
• B. are not subject to federal or state regulation
• C. place primary care at the center of the delivery system
• D. are structured as indemnity plans

Answer: C

NEW QUESTION 7
To measure performance for quality management, health plans collect and analyze three types of data: financial data, clinical data, and customer satisfaction data. The following statement(s) can correctly be made about the sources of clinical data:
* 1.Patient surveys are the most widely used source of disease-specific clinical information
* 2.Outcomes research studies sponsored by academic institutions and professional organizations have limited usefulness for particular health plans or individual providers
* 3.The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys address both physical and mental health status

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

Answer: C

NEW QUESTION 8
This agency’s accreditation decisions are based on the results of an on-site survey of clinical and administrative systems and processes, as well as the health plan’s performance on selected effectiveness of care and member satisfaction measures.

• A. American Accreditation HealthCare Commission/URAC (URAC)
• B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• C. Community Health Accreditation Program (CHAP)
• D. National Committee for Quality Assurance (NCQA)

Answer: D

NEW QUESTION 9
One difference between outcomes research and clinical research is that outcomes research

• A. provides an absolute measure of treatment results, whereas clinical research provides a relative measure of results
• B. focuses on treatment effectiveness, whereas clinical research focuses on treatmentefficacy
• C. examines diseases and treatments in isolation, whereas clinical research considers the effects of changes in health status and quality of life
• D. gathers outcomes data from controlled clinical trials, whereas clinical research collects and analyzes clinical, financial, and administrative data

Answer: B

NEW QUESTION 10
The paragraph below contains two pairs of phrases enclosed in parentheses. Select the phrase in each pair that correctly completes the paragraph. The select the answer choice containing the two phrases you have selected.
Calvin Montrose, age 75, has difficulty performing basic self-care activities, such as bathing, dressing, and eating, without assistance. This information indicates that Mr. Montrose needs assistance with (activities of daily living / instrumental activities of daily living) that are used to measure his (functional status / health status).

• A. activities of daily living / functional status
• B. activities of daily living / health status
• C. instrumental activities of daily living / functional status
• D. instrumental activities of daily living / health status

Answer: A

NEW QUESTION 11
One method that health plans use to address provider compliance with formularies is academic detailing.

• A. True
• B. False

Answer: A

NEW QUESTION 12
The following statements are about chronic and disabling conditions among children eligible for Medicaid. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. Children with chronic conditions use more physician and nonphysician professional services than do children in the general population.
• B. The majority of chronic conditions affecting children in Medicaid programs are the same as those affecting children in the general population.
• C. Medicaid-eligible children are at risk for seriousmental and physical conditions.
• D. Children in Medicaid programs have a higher incidence of chronic disabling conditions than do children in the general population.

Answer: B

NEW QUESTION 13
The Fairview Health Plan uses a dual database approach to integrate information needed for its disease management program. This information indicates that Fairview uses an information management system that

• A. combines all existing information from all data sources into a single comprehensive system
• B. connects multiple databases with a central interface engine that acts as an information clearinghouse
• C. provides an outside vendor with pertinent data that the vendor compiles into an integrated database
• D. creates a separate database that pulls pertinent information from the health plan’s claims database, formats the information for easy analysis, and stores it in the separate database

Answer: D

NEW QUESTION 14
Economically, health plans cannot provide coverage for every drug available from every manufacturer. As a result, purchaser contracts often include provisions specifying that certain drugs or drug types will not be covered. These provisions are referred to as

• A. limitations
• B. exceptions
• C. exclusions
• D. drug edits

Answer: C

NEW QUESTION 15
Elaine Newman suffered an acute asthma attack and was taken to a hospital emergency department for treatment. Because Ms. Newman’s condition had not improved enough following treatment to warrant immediate release, she was transferred to an observation care unit. Transferring Ms. Newman to the observation care unit most likely

• A. resulted in unnecessarily expensive charges for treatment
• B. prevented M
• C. Newman from receiving immediate attention for her condition
• D. gave M
• E. Newman access to more effective and efficient treatment than she could have obtained from other providers in the same region
• F. allowed clinical staff an opportunity to determine whether M
• G. Newman required hospitalization without actually admitting her

Answer: D

NEW QUESTION 16
Administrative action plans are used when performance problems or opportunities are related to the way the organization itself operates. The following statement(s) can correctly be made about administrative action plans:
* 1.Administrative action plans allow health plans to coordinate management activities
* 2.One function of administrative action plans is to integrate service across all levels of the organization
* 3.Administrative action plans are designed to improve outcomes by helping plan members assume responsibility for their own health

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

Answer: B

NEW QUESTION 17
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