Avant-garde Network Management AHM-530 Pdf Exam

NEW QUESTION 1

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.
Because Mr. Pelham was injured on the job, he is entitled to receive benefits through workers’ compensation. Under the terms of the state-mandated exclusive remedy doctrine included in the workers’ compensation agreement, Mr. Pelham will most likely be prohibited from

• A. Receiving workers’ compensation benefits unless he can show that the employer was at fault for his injury
• B. Obtaining care from providers who are not members of a workers’ compensation network
• C. Suing his employer for additional benefits
• D. Claiming benefits from both workers’ compensation and his group health plan

Answer: C

NEW QUESTION 2

With respect to contractual provisions related to provider-patient communications, nonsolicitation clauses prohibit providers from

• A. Encouraging patients to switch from one health plan to another
• B. Disclosing confidential information about the health plan’s reimbursement structure
• C. Dispersing confidential financial information regarding the health plan
• D. Discussing alternative treatment plans with patients

Answer: A

NEW QUESTION 3

The Argyle Health Plan has contracted to obtain the services of the providers in the Column Medical Group, a faculty practice plan (FPP). The following statement(s) can correctly be made about this contract:

• A. Column most likely contracted with the legal group representing the FPP rather than with the individual physicians within the FPP.
• B. Column most likely will provide only highly specialized care to Argyle's plan members.
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: B

NEW QUESTION 4

In most states, workers’ compensation is first-dollar and last-dollar coverage, which means thatworkers’ compensation programs

• A. Can place limits on the benefits they will pay for a given claim
• B. Can deny coverage for work-related illness or injury if the employer is not at fault
• C. Must pay 100% of work-related medical and disability expenses
• D. Can hold employers liable for additional amounts that result from court decisions

Answer: C

NEW QUESTION 5

The following statements are about managed dental care. Three of these statements are true, and one is false. Select the answer choice containing the FALSE statement.

• A. Managed dental care is federally regulated.
• B. Dental HMOs typically need very few healthcare facilities because almost all dental services are delivered in an ambulatory care setting.
• C. Currently, there are no nationally recognized standards for quality in managed dental care.
• D. Processes for selecting dental care providers vary greatly according to state regulationson managed dental care networks and the health plan’s standards.

Answer: A

NEW QUESTION 6

Health plan contract negotiations with an integrated delivery system (IDS) or a hospital are usually lengthier and more complex than negotiations with a single-specialty provider.

• A. True
• B. False

Answer: A

NEW QUESTION 7

The Omni Health Plan is interested in expanding the specialty services it offers to its plan members and is considering contracting with the following providers of specialty services:
The Apex Company, a managed vision care organization (MVCO) The Baxter Managed Behavioral Healthcare Organization (MBHO) The Cheshire Dental Health Maintenance Organization (DHMO)
As part of its credentialing process, Omni would like to verify that each of these providers has met NCQA’s accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for

• A. Apex and Baxter only
• B. Apex and Cheshire only
• C. Baxter and Cheshire only
• D. Baxter only

Answer: D

NEW QUESTION 8

Although ambulatory payment classifications (APCs) bear some resemblance to diagnosis- related groups (DRGs), there are significant differences between APCs and DRGs. One of these differences is that APCs:

• A. typically allow for the assignment of multiple classifications for an outpatient visit
• B. always apply to a patient's entire hospital stay
• C. typically serve as a payment system for inpatient services
• D. typically include reimbursements for professional fees

Answer: A

NEW QUESTION 9

The method of pharmaceutical reimbursement under which a plan member obtains prescription drugs from participating network pharmacies by presenting proper identification and paying a specified copayment is the

• A. Wholesale acquisition cost (WAC) approach
• B. Reimbursement approach
• C. Service approach
• D. Cognitive approach

Answer: C

NEW QUESTION 10

The Ross Health Plan compensates Dr. Cecile Sanderson on a FFS basis. In order to increase the level of reimbursement that she would receive from Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The services she actually provided represented an intermediate level of service. Dr. Sanderson’s action is an example of a type of false billing procedure known as

• A. Cost shifting
• B. Churning
• C. Unbundling
• D. Upcoding

Answer: D

NEW QUESTION 11

The following statements describe two types of HMOs:
The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.
The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.
Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an
IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.
Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:
The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents per tablet for this drug.
The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.
To calculate its drug costs, Elm uses a pricing system known as:

• A. Estimated acquisition cost (EAC)
• B. Package rate cost (PRC)
• C. Actual acquisition cost (AAC)
• D. Wholesale acquisition cost (WAC)

Answer: A

NEW QUESTION 12

Following statements are about accreditation of health plans:

• A. The National Committee for Quality Assurance (NCQA) serves as the primary accrediting agency for most health maintenance organizations (HMOs).
• B. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has developed standards that can be used for the accreditation of hospitals, but not for the accreditation of health plan provider networks or health plan plans.
• C. States are required to adopt the model standards developed by the National Association of Insurance Commissioners (NAIC), an organization of state insurance regulators that develops standards to promote uniformity in insurance regulations.
• D. Accreditation is an evaluative process in which a health plan undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the federal government or by the state governments.

Answer: A

NEW QUESTION 13

The provider contract that Dr. Bijay Patel has with the Arbor Health Plan includes a no- balance-billing clause. The purpose of this clause is to:

• A. prohibit D
• B. Patel from collecting payments from Arbor plan members for medical services that he provided them, even if the services are explicitly excluded from the benefit plan
• C. allow D
• D. Patel to bill patients for services only if the services are considered to be medically necessary
• E. establish the guidelines used to determine if Arbor is the primary payor of benefits in a situation in which an Arbor plan member is covered by more than one health plan
• F. require D
• G. Patel to accept Arbor's payment as payment in full for medical services that he provides to Arbor plan members

Answer: D

NEW QUESTION 14

The following activities are the responsibility of either the Nova Health Plan's risk management department or its medical management department:

• A. Protecting Nova's members against harm from medical care
• B. Improving the overall health status of Nova members by coordinating care across individual episodes of care and the different providers who treat the member
• C. Protecting Nova against financial loss associated with the delivery of healthcare
• D. Establishing outreach programs to encourage the use of preventive health services by Nova's members of these activities, the ones that are more likely to be the responsibility of Nova's risk management department rather than its medical management department are activities:
• E. A, B, and C
• F. A, C, and D
• G. A and C
• H. B and D

Answer: C

NEW QUESTION 15

Open panel health plans can contract with individual providers or with various provider groups when developing their networks. The following statements are about factors that an open panel health plan might consider in contracting with different types of provider organizations. Select the answer choice that contains the correct statement.

• A. One limitation of contracting with multispecialty groups is that a health plan obtains only specialty consultants, but not PCPs.
• B. One benefit to a health plan in contracting with an integrated delivery system (IDS) is the ability to have a network in rapid order and to enter into a new market or one that is already competitive.
• C. A health plan that contracts with an individual practice association (IPA) has a greater ability to select and deselect individual physicians than when contracting directly with the providers.
• D. A health plan that contracts with an IDS is able to eliminate the antitrust risk that exists when contracting with an IPA.

Answer: B

NEW QUESTION 16

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 17

In contracting with providers, a health plan can use a closed panel or open panel approach. One statement that can correctly be made about an open panel health plan is that the participating providers

• A. must be employees of the health plan, rather than independent contractors
• B. are prohibited from seeing patients who are members of other health plans
• C. typically operate out of their own offices
• D. operate according to their own standards of care, rather than standards of care established by the health plan

Answer: C

NEW QUESTION 18

Social health maintenance organizations (SHMOs) and Programs of All-Inclusive Care for the Elderly (PACE) are federal programs designed to provide coordinated healthcare services to the elderly. Unlike PACE, SHMOs

• A. are reimbursed solely through Medicaid programs
• B. provide extensive long-term care
• C. are reimbursed on a fee-for-service basis
• D. limit benefits to a specified maximum amount

Answer: D

NEW QUESTION 19
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