Top Tips Of Replace AHM-510 Testing Software

NEW QUESTION 1
Determine whether the following statement is true or false:
Although most-favored-nation (MFN) clauses in contracts between health plans and healthcare providers are not per se illegal, they should be reviewed under the rule of reason analysis for antitrust purposes.

• A. True, because the Federal Trade Commission (FTC) ruled that MFN clauses are not per se illegal and the FTC encourages health plans to include them in provider contracts.
• B. True, because although MFN clauses are not per se illegal, they violate antitrust laws if they have a predatory purpose and an anticompetitive effect.
• C. False, because MFN clauses involve decisions by providers concerning the level of fees to charge, and thus they are per se illegal.
• D. False, because MFN clauses are not per se illegal, and thus they are exempt from antitrust laws and regulation by the FTC.

Answer: B

NEW QUESTION 2
Arthur Dace, a plan member of the Bloom Health Plan, tried repeatedly over an extended period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr. Dace informally surveyed other Bloom plan members and found that many people were experiencing similar problems getting an appointment with this particular provider. Mr. Dace threatened to take legal action against Bloom, alleging that the health plan had deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making it difficult for patients to make appointments with Dr. Pyle.
Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR)
method that is quicker and less expensive than litigation. Under this ADR method, both Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who issued a decision that Bloom's utilization management practices in this case did not constitute a form of abuse. The panel's decision is legally binding on both parties.
This information indicates that Bloom resolved its dispute with Mr. Dace by using an ADR method known as:

• A. Corporate risk management
• B. An ombudsman program
• C. An ethics committee
• D. Arbitration

Answer: D

NEW QUESTION 3
There are several exceptions to the Ethics in Patient Referrals Act and its amendments (the Stark laws), which prohibit a physician from referring Medicare or Medicaid patients for certain designated services or supplies provided by entities in which the physician has a financial interest. Consider whether the situations described below qualify as exceptions to the Stark laws:
Situation A: Dr. Wong is a physician in the Marvel Health Plan's provider network and has a financial relationship with Marvel arising from the health plan's compensation for his services. Marvel is not a prepaid health plan.
Situation B: Dr. Ryder is a physician in the provider network of the Glen Health Plan, which is not a prepaid health plan. In situations of medical necessity, Dr. Ryder refers Glen patients to a physical therapy clinic that leases office space from him.
Situation C: Dr. Yost has a compensation arrangement with a health plan for providing health services under the Medicare+Choice program.
An arrangement that is exempt from the Stark laws is described in

• A. All of these situations
• B. Situations A and C only
• C. Situation B only
• D. Situation C only

Answer: D

NEW QUESTION 4
Greenpath Health Services, Inc., an HMO, recently terminated some providers from its network in
response to the changing enrollment and geographic needs of the plan. A provision in Greenpath's contracts with its healthcare providers states that Greenpath can terminate the contract at any
time, without providing any reason for the termination, by giving the other party a specified period of notice.
The state in which Greenpath operates has an HMO statute that is patterned on the NAIC HMO Model Act, which requires Greenpath to notify enrollees of any material change in its provider network. As required by the HMO Model Act, the state insurance department is conducting an examination of Greenpath's operations. The scope of the on-site examination covers all aspects of Greenpath's market conduct operations, including its compliance with regulatory requirements. From the following answer choices, select the response that identifies the type of market conduct examination that is being performed on Greenpath and the frequency with which the HMO Model Act requires state insurance departments to conduct an examination of an HMO's operations.

• A. Type of examination: comprehensive; Required frequency: annually
• B. Type of examination: comprehensive; Required frequency: at least every three years
• C. Type of examination: target; Required frequency: annually
• D. Type of examination: target; Required frequency: at least every three years

Answer: B

NEW QUESTION 5
The following statements are about market conduct examinations of health plans. Select the answer choice that contains the correct statement.

• A. Multistate examinations are not appropriate for financial examinations, because regulatory requirements concerning a health plan's financial condition tend to vary from state to state.
• B. Market conduct examinations of a health plan's advertising and sales materials include comparing the advertising materials to the policies they advertise.
• C. Once an examination report is provided to the state insurance department, a health plan is not given an opportunity to present a formal objection to the report.
• D. In imposing sanctions on health plans, state insurance departments are required to follow federal sentencing guidelines.

Answer: B

NEW QUESTION 6
There are several approaches to the interagency division of responsibility for managed care entity (MCE) oversight. In State M, the state Medicaid agency, the state department of health, and the state insurance department are all responsible for ensuring that quality improvement programs are in place among the same group of MCEs and that these programs meet each agency's rules and regulations for such programs. This information indicates that State M uses the approach known as the

• A. Parallel model
• B. Shared model
• C. Concurrent model
• D. PACE model

Answer: C

NEW QUESTION 7
From the following answer choices, choose the term that best corresponds to this description. Barrington Health Services, Inc. contracts with a state Medicaid agency as a fiscal intermediary. Barrington does not provide medical services, but contracts with medical providers on behalf of the state Medicaid agency.

• A. Health insuring organization (HIO)
• B. Independent practice association (IPA)
• C. Physician practice management (PPM) company
• D. Peer review organization (PRO)

Answer: A

NEW QUESTION 8
The following situations illustrate per se violations of federal antitrust laws:
Situation A - Two groups of providers agreed among themselves that each provider will do business with health plans only on a fee-for-service basis.
Situation B - In order to avoid competing with each other, two independent, competing physicianhospital organizations (PHOs) divide the geographic areas in which they will market their services.
From the following answer choices, select the response that correctly identifies the types of per se violations illustrated by these situations.

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

Answer: A

NEW QUESTION 9
The Wentworth Corporation uses a self-funded plan to provide its employees with healthcare
benefits. One consequence of Wentworth's approach to providing healthcare benefits is that selffunding

• A. Requires that Wentworth self-administer its healthcare benefit plan
• B. Requires that Wentworth pay higher state premium taxes than do insurers and health plans
• C. Eliminates the need for Wentworth to pay a risk charge to an insurer or health plan
• D. Increases the number of benefit and rating mandates that apply to Wentworth's plan

Answer: C

NEW QUESTION 10
The Westchester Health Plan is using a pricing strategy that involves setting a low price in a highly price-sensitive market to stimulate revenue growth. In following this strategy, Westchester is sacrificing short-term profits for fast growth in selected markets. This information indicates that Westchester is following the pricing strategy known as

• A. Market skimming
• B. Buying market share
• C. Price skimming
• D. Unitary pricing

Answer: B

NEW QUESTION 11
Several states have adopted clinical practice guidelines for treating workers' compensation injuries. Clinical practice guidelines can best be described as

• A. Fee schedules that specify the maximum amount providers may charge for treating workers' compensation patients
• B. A utilization management and quality management mechanism designed to aid providers in making decisions about the most appropriate course of treatment for a specific case
• C. Detailed plans of medical treatment designed to facilitate a patient's return to the workplace
• D. Payment practices that might technically violate the provisions of the anti-kickback statute but that will not be considered illegal and for which providers and health plans will not be subject to penalties

Answer: B

NEW QUESTION 12
The following statements appear in the Twilight Health Plan's strategic plan:
Increase the percentage of preventive health interventions for total eligible membership during each of the next three calendar years for the following services: mammography, Pap smears, immunizations, and first trimester visits for prenatal mothers
Improve customer satisfaction on an annual basis for each of the next three calendar years, as measured by satisfaction surveys for members, providers, and employer groups
Increase by 30% the number of claims processed by the automated claim payment system and reduce by 10% the cost of paying claims during the next three years
These statements are examples of Twilight's

• A. Corporate objectives
• B. Company mission
• C. Company vision
• D. Corporate strategies

Answer: A

NEW QUESTION 13
Directors on a health plan's board must demonstrate their compliance with three duties in all their decisions. Directors who exercise their duties in good faith and with the same degree of diligence and skill that an ordinary, reasonable person would be expected to display in the same situation are meeting the duty known as the

• A. Duty of loyalty
• B. Duty to supervise
• C. Duty of care
• D. Trustee duty

Answer: C

NEW QUESTION 14
The Sawgrass Health Center is an institution that trains healthcare professionals and performs various clinical and other types of healthcare-related research. Because Sawgrass receives government funding, it is required to provide medical care for the poor. Of the following types of health plans, Sawgrass can best be described as:

• A. A medical foundation
• B. An academic medical center (AMC)
• C. A healthcare cooperative
• D. A community health center (CHC)

Answer: B

NEW QUESTION 15
Congress enacted three clauses relating to the preemptive effect of the Employee Retirement Income Security Act of 1974 (ERISA). One of these clauses preserves from ERISA preemption any state law that regulates insurance, banking, or securities, with the exception of the exemption for self-funded employee benefit plans. This clause is called the

• A. Savings clause
• B. Preemption clause
• C. Deemer clause
• D. De novo clause

Answer: A

Explanation:
The savings clause preserves from preemption any state law that regulates insurance, banking or securities except as provided by the deemer clause.

NEW QUESTION 16
SoundCare Health Services, an MCO, recently conducted a situation analysis. One step in this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activity
provided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detecting violations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.
By definition, the activity that SoundCare conducted when it examined its strengths, weaknesses, and capabilities is known as

• A. An environmental analysis
• B. An internal assessment
• C. An environmental forecast
• D. A community analysis

Answer: B

NEW QUESTION 17
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