A Review Of Approved AHM-530 Braindump

NEW QUESTION 1

Determine whether the following statement is true or false:
The NCQA has established a Physician Organization Certification (POC) program for the purpose of certifying medical groups and independent practice associations for delegation of certain NCQA standards, including data collection and verification for credentialing and recredentialing.

• A. True
• B. False

Answer: A

NEW QUESTION 2

Edward Patillo has established a Medicare+Choice medical savings account (MSA). This MSA will allow Mr. Patillo to:

• A. Carry over any money remaining in his MSA at the end of the benefit year to the next benefit year
• B. Make withdrawals at any time from the MSA, but only for medical expenses
• C. Obtain payment at 100% of the Medicare allowable payment for all Medicare-covered services he receives, without having to pay any deductibles or out-of-pocket expenses
• D. Make withdrawals from the MSA to meet qualified medical expenses that are not paid by his high-deductible health insurance policy, but these withdrawals are taxed as income to M
• E. Patillo

Answer: A

NEW QUESTION 3

The employees of the Trilogy Company are covered by a typical workers' compensation program. Under this coverage, Trilogy employees are bound by the exclusive remedy doctrine, which most likely:

• A. Allows Trilogy to deny benefits for an employee's on-the-job injury or illness, but only if Trilogy is not at fault for the injury or illness.
• B. Allows Trilogy to place limits on the amount of coverage payable for a given claim under the workers' compensation program.
• C. Requires the employees to accept workers' compensation as their only compensation in cases of work-related injury or illness.
• D. Provides the employees with 24-hour coverage.

Answer: C

NEW QUESTION 4

The Sweeney Health Plan uses the discounted fee-for-service (DFFS) method to compensate some of its providers. Under this method of compensation, Sweeney calculates payments based on

• A. The standard fees of indemnity health insurance plans, adjusted by region
• B. The Medicare fee schedules used by other health plans, adjusted by region
• C. Whichever amount is higher, the billed charge or the DFFS amount
• D. Whichever amount is lower, the billed charge or the DFFS amount

Answer: D

NEW QUESTION 5

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.
A formulary lists the drugs and treatment protocols that are considered to be the preferred
therapy for a given managed population. The Fairfax Health Plan uses the type of formulary which covers drugs that are on its preferred list as well as drugs that are not on its preferred list. This information indicates that Fairfax uses the (closed / open) formulary method. In using the formulary approach to pharmacy benefits management, Fairfax most likely experiences (higher / lower) costs for its members’ prescription drugs than it would if it did not use a formulary.

• A. closed / higher
• B. closed / lower
• C. open / higher
• D. open / lower

Answer: D

NEW QUESTION 6

Martin Breslin, age 72 and permanently disabled, is classified as dually-eligible. This information indicates that Mr. Breslin qualifies for coverage by both

• A. Medicare and private indemnity insurance, and Medicare provides primary coverage
• B. Medicare and Medicaid, and Medicare provides primary coverage
• C. Medicaid and private indemnity insurance, and Medicaid provides primary coverage
• D. Medicare and Medicaid, and Medicaid provides primary coverage

Answer: B

NEW QUESTION 7

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 8

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 9

One true statement about the Medicaid program in the United States is that:

• A. The federal financial participation (FFP) in a state's Medicaid program ranges from 20% to 40% of the state's total Medicaid costs
• B. Medicaid regulations mandate specific minimum benefits, under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, for all Medicaid recipients younger than age 30
• C. The individual states have responsibility for administering the Medicaid program
• D. Non-disabled adults and children in low-income families account for the majority of direct Medicaid spending

Answer: C

NEW QUESTION 10

The Edgewood Health Plan uses a combination of structural, process, outcomes, and customer satisfaction measures to evaluate its network providers’ performance. Edgewood would correctly use outcomes measures to evaluate a provider’s

• A. Compliance with specific regulatory or accrediting requirement
• B. Appropriate use of specified procedures
• C. Patient progress following treatment
• D. Patient perceptions about how well the provider addresses medical problems

Answer: C

NEW QUESTION 11

Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be

• A. $42,857
• B. $56,700
• C. $272,160
• D. $680,400

Answer: C

NEW QUESTION 12

One true statement about the responsibilities of providers under typical provider contracts is that most provider contracts:

• A. include a clause which states that providers must maintain open communications with patients regarding appropriate treatment plans, unless the services are not covered by the member's health plan
• B. hold that the responsibility of the provider to deliver services is usually subject to theprovider's receipt of information regarding the eligibility of the member
• C. contain a gag clause or a gag rule
• D. include a clause that explicitly places the responsibility for medical care on the health plan rather than on the provider of medical services

Answer: B

NEW QUESTION 13

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 14

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement.
One important activity within the scope of network management is ensuring the quality of the health plan’s provider networks. A primary purpose of ________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan’s preestablished criteria for participation in the network.

• A. authorization
• B. provider relations
• C. credentialing
• D. utilization management

Answer: C

NEW QUESTION 15

The following statements are about the inclusion of unified pharmacy benefits in health plan healthcare packages. Select the answer choice containing the correct statement.

• A. When pharmacy benefits management is incorporated into an health plan’s operations as a unified benefit, the health plan establishes pharmacy networks, but a pharmacy benefits management (PBM) company manages their operations.
• B. Under a unified pharmacy benefit, an health plan cannot use mail-order services to provide drugs to its members.
• C. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs typically give health plans more control over patient access to prescription drugs.
• D. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs make drug therapy interventions for plan members more difficult.

Answer: C

NEW QUESTION 16

The provider contracts that the Indigo Health Plan has with its providers include a clause which states that Indigo's denial of payment for a certain medical procedure does not constitute a medical opinion and is not intended to interfere with the provider-patient relationship. This information indicates that Indigo's provider contracts include:

• A. A business confidentiality clause.
• B. A scope of services clause.
• C. An informed refusal clause.
• D. An exculpation clause.

Answer: D

NEW QUESTION 17

As part of the credentialing process, many health plans use the National Practitioner Data Bank (NPDB) to learn information about prospective members of a provider network. One true statement about the NPDB is that:

• A. It is maintained by the individual states
• B. It primarily includes information about any censures, reprimands, or admonishments against any physicians who are licensed to practice medicine in the United States
• C. The information in the NPDB is available to the general public
• D. It was established to identify and discipline medical practitioners who act unprofessionally

Answer: D

NEW QUESTION 18
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