A Review Of Refined AHM-540 Braindump

NEW QUESTION 1
Patient safety and medical errors are important concerns for both quality management (QM) and risk management. The following statement(s) can correctly be made about medical errors:
* 1. The complexity of modern medicine and healthcare delivery systems increases patients’ exposure to the risks of medical errors
* 2. Licensing boards for healthcare professionals in all states provide a consistent system of quality oversight and accountability
* 3. Provider compliance with internal incident reporting requirements is low

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

Answer: C

NEW QUESTION 2
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Select the term or phrase in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms or phrases you have chosen.
TRICARE enrollees have the right to challenge authorization and coverage decisions. Such challenges are referred to as (appeals / grievances) and are typically handled by the (TRICARE contractor / Area Field Office).

• A. appeals / TRICARE contractor
• B. appeals / Area Field Office
• C. grievances / TRICARE contractor
• D. grievances / Area Field Office

Answer: A

NEW QUESTION 3
The Mental Health Parity Act (MHPA) of 1996 is a federal law that establishes requirements for behavioral healthcare coverage for group plan members. The MHPA

• A. requires health plans to offer mental health benefits to all eligible members
• B. prohibits health plans that offer mental health benefits from imposing lower annual or lifetime dollar limits on mental illnesses than they do on physical illnesses
• C. provides an exemption for health plans that can demonstrate cost savings of more than 1 percent
• D. prohibits health plans from limiting the number of outpatient visits or inpatient dayscovered under the plan

Answer: B

NEW QUESTION 4
Increased demands for performance information have resulted in the development of various health plan report cards. With respect to most of the report cards currently available, it is correct to say

• A. that they are focused primarily on health maintenance organization (HMO) plans
• B. that they are based on data collected for the Health Plan Employer Data and Information Set (HEDIS) 3.0
• C. that they are used to rank the performance of various health plans
• D. all of the above

Answer: D

NEW QUESTION 5
One way that health plans can make their benefits more appealing to employers and
employees is to offer coverage for specialty services. It is correct to say that specialty services typically

• A. involve the same types of providers and delivery systems as do standard medical services
• B. are a subset of a health plan’s standard medical-surgical services
• C. are not monitored by health plans for quality or utilization
• D. require specialized knowledge for service delivery and management

Answer: D

NEW QUESTION 6
Breanna Osborn is a case manager for a regional health plan. One component of Ms. Osborn’s job is the collection and evaluation of medical, financial, social, and psychosocial information about a member’s situation. This component of Ms. Osborn’s job is known as

• A. case identification
• B. case management planning
• C. healthcare coordination
• D. case assessment

Answer: D

NEW QUESTION 7
Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the

• A. lack of qualified providers in provider networks
• B. lack of resources necessary to establish case management programs for patients with complex conditions
• C. unstable eligibility status of Medicaid recipients
• D. inability of Medicaid recipients to change health plans or PCPs

Answer: C

NEW QUESTION 8
Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located at a military installation. Ms. Wilson serves as a primary point of contact between enrollees and the TRICARE system and answers enrollees’ questions about plan options, eligibility, provider selection, and claims. This information indicates that Ms. Wilson serves as a

• A. lead agent
• B. beneficiary services representative
• C. health plan support contractor
• D. primary care manager (PCM)

Answer: B

NEW QUESTION 9
The following statement(s) can correctly be made about the scope of case management:
* 1. Case management incorporates activities that may fall outside a health plan’s typical responsibilities, such as assessing a member’s financial situation
* 2. Case management generally requires a less comprehensive and complex approach to a course of care than does utilization review
* 3. Case management is currently applicable only to medical conditions that require inpatient hospital care and are categorized as catastrophic in terms of health and/or costs

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

Answer: D

NEW QUESTION 10
Selene Varga is participating in her health plan’s disease management program for congestive heart failure. Ms. Varga’s health status is regularly monitored and managed by a licensed nurse who visits Ms. Varga at her home to administer treatment and assess the need for changes in Ms. Varga’s overall care plan. This information indicates that Ms. Varga is participating in the type of disease management program known as a

• A. coordinated outreach model program
• B. case management model program
• C. hub-and-spoke model program
• D. group clinic model program

Answer: B

NEW QUESTION 11
Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans typically use home healthcare include
* 1. The period prior to a hospital admission
* 2. The period following discharge from a hospital

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

Answer: A

NEW QUESTION 12
Since its inception, Medicare has undergone a number of changes because of legal and regulatory action. One result of the Balanced Budget Act (BBA) of 1997 has been to

• A. expand Medicare benefits by mandating coverage for certain preventive services
• B. reduce the number of organizations that can deliver covered services
• C. encourage growth of managed Medicare programs in all markets
• D. increase the number of “zero premium” plans available to Medicare beneficiaries

Answer: A

NEW QUESTION 13
Comparing the quality of managed Medicare programs with the quality of FFS Medicare programs is often difficult. Unlike FFS Medicare, managed Medicare programs

• A. can measure and report quality only at the provider level
• B. use a single system to deliver services to all plan members
• C. provide an organizational focus for accountability
• D. can use the same performance measures for all products and plans

Answer: C

NEW QUESTION 14
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 you have chosen.
A primary distinction between skilled care and subacute care relates to the extent and medical complexity of the patient’s needs. Generally, subacute care patients require (more
/ fewer) services from physicians and nurses and (more / less) extensive rehabilitation services than do skilled care patients.

• A. more / more
• B. more / less
• C. fewer / more
• D. fewer / less

Answer: A

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
A health plan’s choice of structure measures, process measures, and outcome measures to evaluate performance depends in part on the scientific soundness of the measures. One approach that a health plan can use to enhance scientific soundness is stratification, which refers to the

• A. identification and removal of unusual cases, such as patients with contraindications to a particular treatment, from consideration
• B. statistical adjustment of outcome measures to account for differences in the severity of illness or the presence of other medical conditions
• C. specification of a target population for a procedure and the data collection and analysis methods to be used
• D. elimination of variation within a patient population by dividing the population into groups that are at a similar level of risk

Answer: D

NEW QUESTION 17
The Quality Assessment Performance Improvement (QAPI) is a quality initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare and Medicaid health plan enrollees. The Centers for Medicare and Medicaid Services (CMS) requires compliance with QAPI from

• A. both Medicare+Choice plans and Medicaid health plans
• B. Medicare+Choice plans only
• C. Medicaid health plans only
• D. neither Medicare+Choice plans nor Medicaid health plans

Answer: B

NEW QUESTION 18
Health plans communicate proposed performance changes through action statements. Select the answer choice containing an action statement that includes all of the required elements.

• A. The proportion of adult members who are screened for hypertension will increase by ten percent.
• B. Primary care providers (PCPs) will increase the proportion of children under the age of two who are up-to-date on immunizations by seven percent within one year.
• C. The QM program director will evaluate the level of provider compliance with clinicalpractice guidelines (CPGs).
• D. The disease management program director will increase participation by asthmatic children in the health plan’s pediatric asthma disease management program.

Answer: B

NEW QUESTION 19
The delivery of quality, cost-effective healthcare is a primary goal of both group healthcare and workers’ compensation programs. One difference between group healthcare and workers’ compensation is that workers’ compensation

• A. provides health and disability benefits to employees injured on the job only if the employer is at fault for the injury
• B. provides coverage for a variety of direct and indirect healthcare, disability, and workplace costs
• C. manages costs by including employee cost-sharing features in its benefit design
• D. places limits on benefits by restricting the amount of benefit payments or the number of covered hospital days or provider office visits

Answer: B

NEW QUESTION 20
Health plans have a specified number of working days to respond to Level One appeals, as stated by company policy or regulatory requirements. With regard to the timeframes for appeals, it is generally correct to say
* 1. That the typical timeframe requires a health plan to respond to appeals in fewer than 20 days
* 2. That the timeframe is accelerated for expedited appeals
* 3. That the review period begins when the appeal arrives at a health plan

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

Answer: D

NEW QUESTION 21
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