Leading AHM-250 Dump 2021

NEW QUESTION 1

Dr. Milton Ware, a physician in the Riverside MCO's network of providers, is reimbursed under a fee schedule arrangement for medical services he provides to Riverside members. Dr. Ware's provider contract with Riverside contains a typical no-balance billi

• A. prevent D
• B. Ware from requiring a Riverside member to pay any coinsurance, copayment, or deductibles that the member would normally pay under Riverside's plan
• C. require D
• D. Ware to accept the amount that Riverside pays for medical services as payment in full and not to bill plan members for additional amounts
• E. prevent D
• F. Ware from seeking compensation from patients if Riverside fails to compensate him because of the MCO's insolvency
• G. prevent D
• H. Ware from billing a Riverside member for medical services that are not included in Riverside's plan

Answer: B

NEW QUESTION 2

Which of the following statements is true?

• A. A declining economy can lead to lower healthcare costs as a result of an older population with greater healthcare needs.
• B. A larger patient population increases pressure on the health plan to offer larger panels.
• C. Provider networks are not affected by the federal and state laws that apply to health plans
• D. Network management standards established by independent accrediting organizations have no influence on health plan network design.

Answer: B

NEW QUESTION 3

Lansdale Healthcare, a health plan, offers comprehensive healthcare coverage to its members through a network of physicians, hospitals, and other service providers. Plan members who use in-network services pay a copayment for these services. The copayment

• A. specified dollar amount charge that a plan member must pay out-of-pocket for a specified medical service at the time the service is rendered
• B. percentage of the fees for medical services that a plan member must pay after Magellan has paid its share of the costs of those services
• C. flat amount that a plan member must pay each year before Magellan will make any
• D. benefit payments on behalf of the plan member
• E. specified payment for services that was negotiated between the provider and Magellan

Answer: A

NEW QUESTION 4

The Cleopatra Group, a third-party administrator (TPA), has entered into a TPA agreement with the Alexander MCO with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. On

• A. hold all funds it receives on behalf of Alexander in trust
• B. assume full responsibility for determining the claim payment procedures for the plan
• C. assume full responsibility for ensuring that the health plan is administered properly
• D. obtain from the federal government a certificate of authority designating the Cleopatra Group as a TPA

Answer: A

NEW QUESTION 5

Many of the credentialing standards and criteria used by health plans are often taken from already existing standards established by

• A. the National Practitioner Data Bank (NPDB)
• B. the National Association of Insurance Commissioners (NAIC)
• C. the Centers for Medicare and Medicaid Services (CMS)
• D. independent accrediting organizations

Answer: D

NEW QUESTION 6

One factor the Sandpiper Health Plan uses to assess its quality is a clinician's bedside manner, i.e., how friendly and understanding the clinician is, whether the patient feels that the clinician listens to the patient's concerns, how well the clinical

• A. a provider service quality issue
• B. an administrative service quality issue a healthcare process quality issue
• C. a healthcare outcomes quality issue
• D. a healthcare process quality issue

Answer: A

NEW QUESTION 7

The following statements apply to health reimbursement arrangements. Select the answer choice that contains the correct statement.

• A. Only employers are permitted to establish and fund HRAs.
• B. The popularity of HRAs waned following a 2002 ruling by U.
• C. Treasury Department regarding their treatment in the tax code.
• D. HRAs must be offered in conjunction with a high-deductible health plan.
• E. The guaranteed portability feature of HRAs has contributed to their popularity.

Answer: A

NEW QUESTION 8

Paul Gilbert has been covered by a group health plan for two years. He has been undergoing treatment for angina for the past three months. Last week, Mr. Gilbert began a new job and immediately enrolled in his new company's group health plan, which has a

• A. Can exclude coverage for treatment of M
• B. Gilbert's angina for one year, because HIPAA does not impact a group health plan's pre-existing condition provision.
• C. Can exclude coverage for treatment of M
• D. Gilbert's angina for one year, because M
• E. Gilbert did not have at least 36 months of creditable coverage under his previous health plan.
• F. Can exclude coverage for treatment of M
• G. Gilbert's angina for three months, because that is the length of time he received treatment for this medical condition prior to his enrollment in the new health plan.
• H. Cannot exclude his angina as a pre-existing condition, because the one-year pre- existing condition provision is offset by at least one year of continuous coverage under his previous health plan.

Answer: D

NEW QUESTION 9

Employer-sponsored benefit plans that provide healthcare benefits must comply with the Employee Retirement Income Security Act (ERISA). One of the most significant features of ERISA is that it

• A. contains a provision stating that the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plans
• B. standardizes the conversion of group healthcare benefits to individual healthcare benefits
• C. mandates that self-funded healthcare plans must pay state premium taxes
• D. requires that all active employees, regardless of age, must be eligible for coverage under employer-sponsored benefit plans

Answer: A

NEW QUESTION 10

Several marketplace factors helped fuel the movement toward consumer choice. Which one of the following statements is NOT accurate with regard to these factors?

• A. After a period of relative stability, annual growth in private health spending per capita began to increase rapidly in 2002.
• B. During the height of the recent cost upswing, insurance premiums were increasing by more than 13% annually.
• C. Increased utilization was the largest factor contributing to the rise in premiums, accounting for 43% of the increase.
• D. Employer payers began seeking ways to control spiraling utilization rates and provide lower cost health coverage options.

Answer: A

NEW QUESTION 11

Before the Leo Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the

• A. receive compensation based on the volume and variety for medical services they perform for Leo plan members, whereas the specialists receive compensation based solely on the number of plan members who are covered for specific services
• B. have no financial incentive to practice preventive care or to focus on improving the health of their plan members, whereas the specialists have a positive incentive to help their plan members stay healthy
• C. receive from the IPA the same monthly compensation for each Leo plan member under the PCP's care, whereas the specialists receive compensation based on a percentage discount from their normal fees
• D. receive compensation based on a fee schedule, whereas the specialists receive compensation based on per diem charges

Answer: C

NEW QUESTION 12

An HMO’s quality assurance program must include

• A. A statement of the HMO’s goals and objectives for evaluating and improving enrollees’ health status
• B. Documentation of all quality assurance activities
• C. System for periodically reporting program results to the HMO’s board of directors, its providers, and regulators
• D. All the above

Answer: D

NEW QUESTION 13

One type of physician-only integration model is a consolidated medical group. Typical
characteristics of a consolidated medical group include

• A. that it may be a single-specialty or multi-specialty practice
• B. operates in one or a few facilities rather than in many independent offices
• C. achieves economies of scale in the group's integrated operations
• D. all of the above

Answer: D

NEW QUESTION 14

One distinction that can be made between a staff model HMO and a group model HMO is that, in a staff model HMO, participating physicians are Back to Top

• A. Employees of the HMO
• B. Employees of a group practice that has contracted with the HMO
• C. Compensated primarily through capitation
• D. Limited to primary care physicians (PCPs)

Answer: A

NEW QUESTION 15

One typical characteristic of an integrated delivery system (IDS) is that an IDS.

• A. Is more highly integrated structurally than it is operationally.
• B. Provides a full range of healthcare services, including physician services, hospital services, and ancillary services.
• C. Cannot negotiate directly with health plans, plan sponsors, or other healthcare purchasers.
• D. Performs a single business function, such as negotiating with health plans on behalf of all of the member providers.

Answer: B

NEW QUESTION 16

The following statements are about concepts related to the underwriting function within a health plan. Select the answer choice containing the correct statement.

• A. Anti selection refers to the fact that individuals who believe that they have a less-than-
• B. average likelihood of loss tend to seek healthcare coverage to a greater extent than do individuals who believe that they have an average or greater-than-average like
• C. Federally qualified HMOs are required to medically underwrite all groups applying for coverage.
• D. Typically, a health plan guarantees the premium rate for a group health contract for a period of five years.
• E. When evaluating the risk for a group policy, underwriters typically focus on such factors as the size of the group, the stability of the group, and the activities of the group.

Answer: D

NEW QUESTION 17

More procedures or services may be fully covered within the PPO network than those out of network.

• A. True
• B. False

Answer: A

NEW QUESTION 18

The data evaluation stage of utilization review (UR) includes both administrative reviews and medical reviews. One true statement about these types of reviews is that:

• A. An administrative review must be conducted by a health plan staff member who is a medical professional.
• B. The primary purpose of an administrative review is to evaluate the appropriateness of a proposed medical service.
• C. UR staff members typically conduct a medical review of a proposed medical service before they conduct an administrative review for that same service.
• D. One purpose of a medical review is to evaluate the medical necessity of a proposed medical service.

Answer: D

NEW QUESTION 19

The following statements describe two types, or models, of HMOs:
The Quest HMO has contracted with only one multi-specialty group of physicians. These physicians are employees of the group practice, have an equity interest in the practice, and provide

• A. A captive group a staff model
• B. A captive group a network model
• C. An independent group a network model
• D. An independent group a staff model

Answer: B

NEW QUESTION 20

Brokers are one type of distribution channel that health plans use to market their health plans. One true statement about brokers for health plan products is that, typically, brokers

• A. Are not required to be licensed by the states in which they market health plans
• B. Are compensated on a salary basis
• C. Represent only one health plan or insurer
• D. Are considered to be an agent of the buyer rather than an agent of the health plan or Insurer

Answer: D

NEW QUESTION 21

One way that MCOs involve providers in risk sharing is by retaining a percentage of the providers' payment during a plan year. At the end of the plan year, the MCO may use the amount retained to offset or pay for any cost overruns for referral or hospital

• A. withholds
• B. usual, customary, and reasonable (UCR) fees
• C. risk pools
• D. per diems

Answer: A

NEW QUESTION 22

Health plans may use different capitation arrangements for different levels of service. One typical capitation arrangement provides a capitation payment that may include primary care only, or both primary and secondary care, but not ancillary services. The

• A. global capitation arrangement
• B. gatekeeper arrangement
• C. carve-out arrangement
• D. partial capitation arrangement

Answer: D

NEW QUESTION 23

Historically most HMOs have been

• A. Closed-access HMO
• B. Closed-panel HMO
• C. Open-access HMO
• D. Open-panel HMO

Answer: B

NEW QUESTION 24

Federal legislation has placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level.
This federal legislation is the

• A. Clayton Act
• B. Federal Trade Commission Act
• C. McCarran-Ferguson Act
• D. Sherman Act

Answer: C

NEW QUESTION 25

To determine fee reimbursements to be paid to physicians, the Triangle Health Plan assigns a weighted value to each medical procedure or service and multiplies the weighted value by a money multiplier. Triangle and the providers negotiate the value of the

• A. Diagnosis-related group (DRG) system
• B. Relative value scale (RVS)
• C. Partial capitation arrangement
• D. Capped fee system

Answer: B

NEW QUESTION 26

Using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider is called

• A. Coding error
• B. Overcharging
• C. Upcoming
• D. Unbundling

Answer: C

NEW QUESTION 27

When determining the premium rates it will charge a particular group, the Blue Jay Health Plan used a rating method known as community rating by class (CRC). Under this rating method, Blue Jay

• A. was allowed to use no more than four rating classes when determining how much to charge the group for health coverage
• B. was required to make the average premium in each class no more than 105% of the average premium for any other class
• C. divided its members into rating classes based on demographic factors, experience, or industry characteristics, and then charged each member in a rating class the same premium
• D. charged all employers or other group sponsors the same dollar amount for a given level of medical benefits, without adjustments for age, gender, industry, or experience

Answer: C

NEW QUESTION 28

When determining the rates it will charge a small group, the Eagle HMO, a federally qualified HMO, divides its members into classes or groups based on demographic factors such as geography, family composition, and age. Eagle then charges all members of a

• A. Retrospective experienced rating.
• B. Adjusted community rating (ACR).
• C. Pure community rating.
• D. Standard community rating.

Answer: B

NEW QUESTION 29
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