AHM-530 | Top Tips Of Improved AHM-530 Practice

NEW QUESTION 1

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 NewnanGroup, 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.
The following statements can correctly be made about the reimbursement for Drugs A and B under the MAC pricing system:

• A. Treble most likely is obligated to reimburse Manor 14 cents per tablet for Drug A.
• B. Manor most likely is allowed to bill the subscriber 2 cents per tablet for Drug A.
• C. Treble most likely is obligated to reimburse Manor 5 cents per tablet for Drug B.
• D. All of the above statements are correct.

Answer: C

NEW QUESTION 2

If a third party is responsible for injuries to a plan member of the Hope Health Plan, then Hope has a contractual right to file a claim for the resulting healthcare costs against the third party. This contractual right to recovery from the third party is known as

• A. Subrogation
• B. Partial capitation
• C. Coordination of benefits
• D. Aremedy provision

Answer: A

NEW QUESTION 3

The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline.
Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn’s PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn’s dermatology services fund for the first quarter was $15,000. During the quarter, Autumn’s PCPs made 90 referrals, and 20 of these referrals were classified as complicated.
Autumn’s method of reimbursing specialty providers can best be described as a

• A. Disease-specific arrangement
• B. Contact capitation arrangement
• C. Risk adjustment arrangement
• D. Withhold arrangement

Answer: B

NEW QUESTION 4

The following statements are about workers' compensation provider networks. Select the answer choice containing the correct statement:

• A. In order to supply a provider network to furnish healthcare to workers' compensation beneficiaries, a health plan typically uses the network that has already been created for the group health plan.
• B. Typically, case managers for workers' compensation programs are physical therapists.
• C. Most states prohibit the use of fee schedules in order to curb the rising workers' compensation healthcare costs.
• D. Networks serving workers' compensation patients typically include higher concentrations of specialists than do other provider networks.

Answer: D

NEW QUESTION 5

The Portway Hospital is qualified to receive Medicaid subsidy payments as a disproportionate share hospital (DHS). The DHS payments that Portway receives are

• A. Made for services rendered to specific patients
• B. Made with matching state and federal funds
• C. Included in the Medicaid capitation payment made to patients’ health plans
• D. Defined as cost-based reimbursement (CBR) equal to 100% of Portway’s reasonable costs of providing services to Medicaid recipients

Answer: B

NEW QUESTION 6

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 7

The following statements are about the responsibilities that providers are expected to assume under most provider contracts with health plans. Select the answer choice containing the correct statement.

• A. All health plans now include in their provider contracts a statement that explicitly places responsibility for the medical care of plan members on the health plan rather than on the provider.
• B. According to the wording of most provider contracts, the responsibility of providers to deliver medical services to a plan member is not contingent upon the provider’s receipt of information regarding the member’s eligibility for these services.
• C. Most health plans include in their provider contracts a clause which requires providers to maintain open communication with plan members regarding appropriate treatment plans, even if the services are not covered by the member’s health plan.
• D. Most provider contracts require participating providers to discuss health plan payment arrangements with patients who are covered by the plan.

Answer: C

NEW QUESTION 8

The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
Qualitative measures that Azure could use to assess provider performance include an evaluation of how

• A. Quickly the provider responds to plan members’ inquiries
• B. Effectively the provider communicates with plan members
• C. Often the provider refers plan members for ancillary services
• D. Many plan members visit the provider per month

Answer: C

NEW QUESTION 9

Dr. Leona Koenig removed the appendix of a plan member of the Helium health plan. In order to increase the level of reimbursement that she would receive from Helium, Dr. Koenig submitted to the health plan separate charges for the preoperative physical examination, the surgicalprocedure, and postoperative care. All of these charges should have been included in the code for the surgical procedure itself. Dr. Koenig's submission is a misuse of the coding system used by health plans and is an example of:

• A. Upcoding
• B. A wrap-around
• C. Churning
• D. Unbundling

Answer: D

NEW QUESTION 10

Jay Mercer is covered under his health plan’s vision care plan, which includes coverage for clinical eye care but not for routine eye care. Recently, Mr. Mercer had a general eye examination and got a prescription for corrective lenses. Mr. Mercer’s vision care plan will cover.

• A. both the general eye examination and the prescription for corrective lenses
• B. the general eye examination only
• C. the prescription for corrective lenses only
• D. neither the general eye examination nor the prescription for corrective lenses

Answer: D

NEW QUESTION 11

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 12

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 13

An health plan enters into a professional services capitation arrangement whenever the health plan

• A. Contracts with a medical group, clinic, or multispecialty IPA that assumes responsibility for the costs of all physician services related to a patient’s care
• B. Pays individual specialists to provide only radiology services to all plan members
• C. Transfers all financial risk for healthcare services to a provider organization and the provider, in turn, covers virtually all of a patient’s medical expenses
• D. Contracts with a primary care provider to cover primary care services only

Answer: A

NEW QUESTION 14

If the Oconee Health Plan reimburses its specialty care physicians (SCPs) under a typical retainer method, then Oconee pays SCPs

• A. Aseparate amount for each service provided, and the payment amount is based solely on a resource-based relative value scale (RBRVS)
• B. Aspecified fee that remains the same regardless of how much or how little time or effort is spent on the medical service performed
• C. Aset amount each month, and Oconee reconciles its payment at periodic intervals on the basis of actual utilization
• D. Aset amount of cash equivalent to a defined time period’s expected reimbursable charges

Answer: C

NEW QUESTION 15

The introductory paragraph of a provider contract is generally followed by a section called the recitals. The recitals section of the contract typically specifies the

• A. Purpose of the agreement
• B. Manner in which the provider is to bill for services
• C. Definitions of key terms to be used in the contract
• D. Rate at which the provider will be compensated

Answer: A

NEW QUESTION 16

Participating providers in a health plan’s network must undergo recredentialing on a regular basis. During recredentialing, a health plan typically reviews

• A. a provider’s current, updated application information, as well as provider’s peer reviews and performance reports on the provider
• B. a provider’s current, updated application information, as well as the provider’s education and prior work history
• C. a provider’s education and prior work history only
• D. peer reviews and performance reports on a provider and the provider’s prior work history only

Answer: A

NEW QUESTION 17

Factors that are likely to indicate increased health plan market maturity include:

• A. Increased consolidation among health plans.
• B. Increased rate of growth in health plan premium levels.
• C. Areduction in the market penetration of HMO and point-of-service (POS) products.
• D. Areduction in the frequency of performance-based reimbursement of providers.

Answer: A

NEW QUESTION 18

In order to evaluate and manage the performance of individual providers in its provider network, the Quorum Health Plan implemented a program that focuses on identifying the best and worst outcomes and utilization patterns of its providers. This program is also designed to develop and implement strategies such as treatment protocols and practice guidelines to improve the performance of Quorum's providers. This information indicates that Quorum implemented a program known as:

• A. An integrated delivery system (IDS)
• B. A coordinated care program
• C. Ostensible agency
• D. Continuous quality improvement (CQI)

Answer: D

NEW QUESTION 19

A provider contract describes the responsibilities of each party to the contract. These responsibilities can be divided into provider responsibilities, health plan responsibilities, and mutual obligations. Mutual obligations typically include

• A. provisions for marketing the plan’s product
• B. payment arrangements between the plan and the provider
• C. verification of the plan’s eligibility to do business
• D. management of the contents of members’ medical records

Answer: B

NEW QUESTION 20

With respect to hiring practices, one step that a health plan most likely can take to avoid violating the terms of the Americans with Disabilities Act (ADA) is to

• A. Require a medical examination prior to accepting an application for employment
• B. Include in the employment application questions pertaining to health status
• C. Make a conditional offer of employment, and then require the candidate to have an examination prior to granting specific staff privileges
• D. Require applicants to answer questions pertaining to the use of drugs and alcohol

Answer: C

NEW QUESTION 21
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