Top Tips Of Refresh AHM-530 Testing Bible

NEW QUESTION 1

Salvatore Arris is a member of the Crescent Health Plan, which provides its members with a full range of medical services through its provider network. After suffering from debilitating headaches for several days, Mr. Arris made an appointment to see Neal Prater, a physician’s assistant in the Crescent network who provides primary care under the supervision of physician Dr. Anne Hunt. Mr. Prater referred Mr. Arris to Dr. Ginger Chen, an ophthalmologist, who determined that Mr. Arris’ symptoms were indicative of migraine headaches. Dr. Chen prescribed medicine for Mr. Arris, and Mr. Arris had the prescription filled at a pharmacy with which Crescent has contracted. The pharmacist, Steven Tucker, advised Mr. Arris to take the medicine with food or milk. In this situation, the person who functioned as an ancillary service provider is

• A. M
• B. Prater
• C. D
• D. Hunt
• E. D
• F. Chen
• G. M
• H. Tucker

Answer: D

NEW QUESTION 2

The following situations illustrate violations of federal antitrust laws:
Situation A Two HMOs split a large employer group by agreeing to let one HMO market to some company employees and to let the second HMO market to different company employees.
Situation B Members of a physician-hospital organization (PHO) that has significant market share jointly agreed to exclude a physician from joining the PHO solely because that physician has admitting privileges at a competing hospital.
From the following answer choices, select the response that best identifies the types of violations illustrated by these situations:

• A. Situation A: horizontal division of territories; Situation B: group boycott
• B. Situation A: horizontal division of territories; Situation B: exclusive arrangement
• C. Situation A: exclusive arrangement; Situation B: group boycott
• D. Situation A: exclusive arrangement; Situation B: tying arrangement

Answer: A

NEW QUESTION 3

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 4

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 5

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 6

In 1996, the NAIC adopted a standard for health plan coverage of emergency services. This standard is based on a concept known as the:

• A. Due process standard
• B. Subrogation standard
• C. Corrective action standard
• D. Prudent layperson standard

Answer: D

NEW QUESTION 7

The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 allowed competitive medical plans (CMPs) to participate in the Medicare program on a risk basis. Under the terms of Medicare risk contracts, CMPs were required to deliver all medically necessary Medicare- covered services in return for a

• A. fixed monthly capitation payment from CMS
• B. fee-for-service payment from the appropriate state Medicare agency
• C. mandatory premium paid by plan enrollees
• D. fee equal to twice the actuarial value of the Medicare deductible and coinsurance paid by plan enrollees

Answer: A

NEW QUESTION 8

Factors that are likely to indicate increased health plan market maturity include:

• A. Increased consolidation among health plans.
• B. Increased rate of growth in health plan premium levels.
• C. Areduction in the market penetration of HMO and point-of-service (POS) products.
• D. Areduction in the frequency of performance-based reimbursement of providers.

Answer: A

NEW QUESTION 9

The provider contract between the Ocelot Health Plan and Dr. Enos Zorn, one of the health plan’s participating providers, is a brief contract which includes, by reference, an Ocelot provider manual. This manual contains much of the information found in Ocelot’s comprehensive provider contracts. The following statements are about Dr. Zorn’s provider contract. Select the answer choice containing the correct statement.

• A. All statements in the provider contract shall be deemed to be warranties, because all statements of facts contained in the contract must be true only in those respects material to the contract.
• B. Because the provider manual is part of the contract, Ocelot must make sure that its provider manual is comprehensive and up-to-date.
• C. Because the provider contract is a brief contract, Ocelot most likely is prohibited from amending the contract unilaterally, even if it gives D
• D. Zorn advance notice of its intent to amend the contract.
• E. Areas that should be covered in the provider manual, and not in the body of the contract, include any specific legal issues relevant to the contract.

Answer: B

NEW QUESTION 10

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 11

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 12

The provider contract that Dr. Lorena Chau has with the Fiesta Health Plan includes an evergreen clause. The purpose of this clause is to:

• A. Allow Fiesta to change or amend the contract without D
• B. Chau's approval as long as the modifications are made in order to comply with new legal and regulatory requirements
• C. Prohibit D
• D. Chau from encouraging her patients to switch from Fiesta to another health plan
• E. Prohibit D
• F. Chau from encouraging her patients to switch from Fiesta to another health plan
• G. Assure that D
• H. Chau provides Fiesta members with healthcare services in a timely manner appropriate to the member's medical condition

Answer: C

NEW QUESTION 13

One type of fee schedule payment system assigns a weighted unit value for each medical procedure or service based on the cost and intensity of that service. Under this system, the unit values for procedural services are generally higher than the unit values for cognitive services. This system is known as a

• A. Wrap-around payment system
• B. Relative value scale (RVS) payment system
• C. Resource-based relative value scale (RBRVS) system
• D. Capped fee system

Answer: B

NEW QUESTION 14

The Foxfire Health Plan, which has 20,000 members, contracts with dermatologists on a contact capitation basis. The contact capitation arrangement has the following features:
Foxfire distributes the money in the contact capitation fund once each quarter and the distribution is based on the point totals accumulated by each dermatologist.
Foxfire's per member per month (PMPM) capitation for dermatology services is $1.
The dermatologist receives 1 point for each new referral that is not classified as a complicated referral and 1.5 points for each new referral that is classified as complicated.
During the first quarter, Foxfire's PCPs made 450 referrals to dermatologists and 100 of these referrals were classified as complicated. One dermatologist, Dr. Shareef Rashad, received 42 of these referrals; 6 of his referrals were classified as complicated. Statements that can correctly be made about Foxfire's contact capitation arrangement include:

• A. that the value of each referral point for the first quarter was $120
• B. that the value of Foxfire's contact capitation fund for dermatologists for the first quarter was $20,000
• C. that the payment that Foxfire owed D
• D. Rashad for the first quarter was $6,120
• E. all of the above

Answer: A

NEW QUESTION 15

Grant Pelham is covered by both a workers’ compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.
Mr. Pelham’s group health insurance plan and workers’ compensation both provide benefits to cover expenses incurred as a result of illness or injury. However, unlike traditional group insurance coverage, workers’ compensation

• A. Provides reimbursement for lost wages
• B. Requires employees who suffer a work-related illness or injury to obtain care from specified network providers
• C. Covers all injuries and illnesses, regardless of their cause
• D. Requires employees to share the cost of treatment through deductible, coinsurance, and benefit limits

Answer: A

NEW QUESTION 16

With regard to the compensation of dental care providers in a managed dental care system, it is correct to state that, typically:

• A. dental PPOs compensate dentists on a capitated basis
• B. group model dental HMOs (DHMOs) compensate general dental practitioners on a salaried basis
• C. independent practice association (IPA)-model dental HMOs (DHMOs) capitate general dental practitioners
• D. staff model dental HMOs (DHMOs) compensate dentists on an FFS basis

Answer: C

NEW QUESTION 17

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.
Qualitative measures that Azure could use to assess provider performance include an evaluation of how

• A. Quickly the provider responds to plan members’ inquiries
• B. Effectively the provider communicates with plan members
• C. Often the provider refers plan members for ancillary services
• D. Many plan members visit the provider per month

Answer: C

NEW QUESTION 18

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 19
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