How Many Questions Of AHM-540 Test

NEW QUESTION 1
Private employers are key purchasers of health plan services. The following statement(s) can correctly be made about employer expectations about the quality and cost- effectiveness of healthcare services:
* 1. For both health maintenance organizations (HMOs) and non-HMO plans, employers typically have access to accreditation results and performance measurement reports to help them evaluate the quality of healthcare and service
* 2. Because of employers’ concern about the quality and costs of healthcare services available through health plans, direct contracting has become a dominant model among employers who sponsor health benefit programs for their employees

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

Answer: D

NEW QUESTION 2
Patricia McLeod is a member of the Enterprise Health Plan, which operates in State X. Ms. McLeod is scheduled to undergo a unilateral mastectomy for the treatment of breast cancer. The surgical procedure will be performed by Dr. Kim Lee, a surgical oncologist.
Based on Enterprise’s medical policy, the contract with the purchaser, and Ms. McLeod’s medical condition, Enterprise’s UR staff have determined that the appropriate course of care for Ms.
McLeod includes a 24-hour stay in the hospital following her surgery. State X, however, has a benefit mandate specifying health plan coverage for 48 hours of inpatient post- mastectomy care. In this situation, the length of hospital stay for which Enterprise must offer coverage is

• A. the length of stay deemed appropriate by D
• B. Lee
• C. the 24-hour stay determined to be appropriate by Enterprise’s UR staff
• D. the length of stay deemed appropriate by M
• E. McLeod
• F. the 48-hour length of stay specified by State X

Answer: D

NEW QUESTION 3
Examples of alternative healthcare practitioners are chiropractors, naturopaths, and acupuncturists. The only well-established credentialing standards for alternative healthcare practitioners are those available from NCQA. These NCQA credentialing standards apply to

• A. chiropractors
• B. naturopaths
• C. acupuncturists
• D. all of the above

Answer: A

NEW QUESTION 4
Determine whether the following statement is true or false:
The utilization review (UR) process produces the greatest number of case management referrals.

• A. True
• B. False

Answer: A

NEW QUESTION 5
The following statement(s) can correctly be made about the characteristics of peer review:
* 1.Peer review is applicable to either single episodes of care or to entire programs of care
* 2.Most peer review is conducted concurrently
* 3.Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services furnished to Medicare and Medicaid recipients enrolled in health plans

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

Answer: C

NEW QUESTION 6
The paragraph below contains two pairs of terms in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Health plans use both internal and external standards to assess the quality of the services that they provide. (Internal / External) standards are based on information such as published industry-wide averages or best practices of recognized industry leaders. Health plans primarily rely on (internal / external) standards to evaluate healthcare services.

• A. Internal / internal
• B. Internal / external
• C. External / internal
• D. External / external

Answer: D

NEW QUESTION 7
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 8
The following statements are about health plans’ development of medical policies. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. Technology assessment is applicable only to medical policy development for new medical procedures, devices, drugs, and tests.
• B. Technology assessment provides the scientific rationale for the medical policy section that specifies when a medical service is appropriate and when it is not.
• C. The medical policy development process includes both a clinical and an operational review of a proposed medical policy.
• D. The decision to accept or reject a proposed medical policy often depends on how a new technology compares to currently used interventions.

Answer: A

NEW QUESTION 9
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 10
Determine whether the following statement is true or false:
Immunization programs are a direct means of reducing health plan members’ needs for healthcare services and are typically cost-effective.

• A. True
• B. False

Answer: A

NEW QUESTION 11
Performance variance can be classified as either common cause variance or special cause variance. The following statement(s) can correctly be made about special cause variance:
* 1. Inadequate staffing levels, employee errors, and equipment malfunctions are examples of special cause variance
* 2. Special cause variance is typically more difficult to detect and correct than is common cause variance

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

Answer: B

NEW QUESTION 12
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.
The Millway Health Plan received a 15% reduction in the price of a particular pharmaceutical based on the volume of the drug Millway purchased from the manufacturer. This reduction in price is an example of a (rebate / price discount) and (is / is not) dependent on actual provider prescribing patterns.

• A. rebate / is
• B. rebate / is not
• C. price discount / is
• D. price discount / is not

Answer: D

NEW QUESTION 13
PBMs are accredited by the same organizations that accredit health plans.

• A. True
• B. False

Answer: B

NEW QUESTION 14
Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services

• A. must be offered as separate supplemental benefits or separate products
• B. lack clinical trials to evaluate their safety and effectiveness
• C. are not covered by state or federal consumer protection statutes
• D. focus on a specific illness, injury, or symptom rather than on the whole body

Answer: B

NEW QUESTION 15
The paragraph below contains two pairs of terms enclosed in parentheses. Select the term in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Under a delegation arrangement, the (delegate / delegator) is responsible for performing the delegated function according to established standards, and the (delegate / delegator) is ultimately accountable for any deficiencies in the performance of the function.

• A. delegate / delegate
• B. delegate / delegator
• C. delegator / delegate
• D. delegator / delegator

Answer: B

NEW QUESTION 16
Comorbidity can have a significant impact on the effective implementation of disease management programs. Comorbidity can correctly be defined as the

• A. degree to which the progression of a disease or condition is understood
• B. prevalence or rate of a sickness or injury within a given population
• C. degree of severity of a particular disease or condition
• D. presence of a chronic condition or added complication other than the condition that requires medical treatment

Answer: D

NEW QUESTION 17
Readiness is an important consideration for the development of health promotion programs. Readiness refers to

• A. the availability of previously established health promotion programs to an health plan’s members through employers, providers, or community service agencies
• B. the appropriateness of a program’s educational approach, given the language, literacy level, and cultural sensitivities of the target population
• C. a member’s level of knowledge about existing health risks and problems and the member’s ability and willingness to adopt new health-related behaviors
• D. a member’s access to information technology, such as a video cassette recorder, a computer, or the Internet

Answer: C

NEW QUESTION 18
The Noble Health Plan conducted a cost/benefit analysis of the following four prescription drugs:
BenefitCost Drug A$525$350 Drug B$450$250
Drug C$400$200 Drug D$350$100
According to this analysis, the drug that represents the most efficient use of resources is

• A. Drug A
• B. Drug B
• C. Drug C
• D. Drug D

Answer: D

NEW QUESTION 19
Vision care is typically separated into two categories: routine eye care and clinical eye care. The standard benefit plans offered by most health plans include coverage for
* 1. Routine eye care
* 2. Clinical eye care

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

Answer: C

NEW QUESTION 20
In most health plans, the formulary system is developed and managed by a P&T committee. The P&T committee is responsible for

• A. evaluating and selecting drugs for inclusion in the formulary
• B. overseeing the manufacture, distribution, and marketing of prescription drugs
• C. certifying the medical necessity of expensive, potentially toxic, or nonformulary drugs
• D. all of the above

Answer: A

NEW QUESTION 21
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