AHM-530 | All About Certified AHM-530 Training

NEW QUESTION 1

The Ventnor Health Plan requires the physicians in its provider network to be board certified. Ventnor has received requests to become a part of the network from the following specialists:
Cheryl Stovall, who is currently in the process of completing a residency in her field ofspecialization.
Thomas Kalil, who has completed a residency in his field of specialization and has passed a qualifying examination in that field within two years of completing his residency.
Roger Todd, who has completed a residency in his field of specialization but has not passed a qualifying examination in that field.
Ventnor's requirement of board certification is met by:

• A. Cheryl Stovall, Thomas Kalil, and Roger Todd.
• B. Thomas Kalil and Roger Todd only.
• C. Thomas Kalil only.
• D. None of these individuals.

Answer: C

NEW QUESTION 2

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 3

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 4

Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in

• A. Slower access to BH care for plan members
• B. Increased collaboration between BH providers and PCPs
• C. Fewer specialized BH services for plan members
• D. Decreased continuity of BH care for plan members

Answer: D

NEW QUESTION 5

The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:

• A. Must provide Medicare participants with standard HMO benefits, as well as with limited long-term care benefits
• B. Does not need as great a variety of provider types or as complex a reimbursement method as does a traditional HMO
• C. Receives a payment that is based on reasonable costs and reasonable charges
• D. Most likely provides fewer supportive services than does a traditional HMO, because one of Bruin's goals is to minimize the use of community-based care

Answer: A

NEW QUESTION 6

In health plan pharmacy networks, service costs consist of two components: costs for services associated with dispensing prescription drugs and costs for cognitive services. Cognitive services typically include:

• A. making generic substitutions of drugs
• B. counseling patients about prescriptions
• C. providing patient monitoring
• D. switching prescription drugs to preferred drugs

Answer: B

NEW QUESTION 7

The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.
The per diem reimbursement method will require Gladspell to pay Ellysium a

• A. Fixed rate for each day a plan member is treated in Ellysium’s subacute care facility
• B. Discounted charge for all subacute care services given by Ellysium
• C. Rate that varies depending on patient category
• D. Fixed rate per enrollee per month

Answer: A

NEW QUESTION 8

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.
One statement that can correctly be made about Gardenia’s two-level POS product is that

• A. members who self-refer without first seeing their PCPs will receive no benefits
• B. both Gardenia and the PCPs stand to benefit if the non-provider panels are kept relatively narrow
• C. members will pay higher coinsurance or copayments if they first see their PCPs each time
• D. the plan offers no financial incentives to members to choose an in-network specialist over a non-network specialist

Answer: D

NEW QUESTION 9

From the following answer choices, choose the term that best matches the description.
An integrated delivery system (IDS), which controls most providers in a particular specialty, agrees to provide that specialty service to a health plan only on thecondition that the health planagree to contract with the IDS for other services.

• A. Group boycott
• B. Horizontal division of territories
• C. Tying arrangements
• D. Concerted refusal to admit

Answer: C

NEW QUESTION 10

Some jurisdictions have enacted corporate practice of medicine laws. One effect that corporate practice of medicine laws have had on HMO provider networks is that these laws typically

• A. require incorporated HMOs to practice medicine through licensed employees
• B. require HMOs to form exclusive contracts with physician groups who agree to dedicate all or most of their practices to HMO patients in return for a set payment or revenue-sharing
• C. restrict the ability of staff model HMOs to hire physicians directly, unless the physiciansown the HMO
• D. encourage incorporated HMOs to obtain profits from their provisions of physician professional services

Answer: C

NEW QUESTION 11

From the following answer choices, choose the term that best matches the description.
Members of a physician-hospital organization (PHO) denied membership to a physician solely because the physician has admitting privileges at a competing hospital.

• A. Group boycott
• B. Horizontal division of territories
• C. Tying arrangements
• D. Concerted refusal to admit

Answer: A

NEW QUESTION 12

The provider contract between the Regal Health Plan and Dr. Caroline Quill contains a type of termination clause known as termination without cause. One true statement about this clause is that it

• A. Requires Regal to send a report to the appropriate accrediting agency if the health plan terminates D
• B. Quill’s contract without cause
• C. Requires that Regal must base its decision to terminate D
• D. Quill’s contract on clinical criteria only
• E. Allows either Regal or D
• F. Quill to terminate the contract at any time, without any obligation to provide a reason for the termination or to offer an appeals process
• G. Allows Regal to terminate D
• H. Quill’s contract at the time of contract renewal only, without any obligation to provide a reason for the termination or to offer an appeals process

Answer: C

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 Pine Health Plan has incorporated pharmacy benefits management into its operations to form a unified benefit. Potential advantages that Pine can receive from this action include:

• A. the fact that unified benefits improve the quality of patient care and the value of pharmacy services to Pine's plan members
• B. the fact that control over the formulary and network contracting can give Pine control over patient access to prescription drugs and to pharmacies
• C. the fact that managing pharmacy benefits in-house gives Pine a better chance to meet customer needs by integrating pharmacy services into the plan's total benefits package
• D. all of the above

Answer: D

NEW QUESTION 15

The provider contract that Dr. Bijay Patel has with the Arbor Health Plan includes a no- balance-billing clause. The purpose of this clause is to:

• A. prohibit D
• B. Patel from collecting payments from Arbor plan members for medical services that he provided them, even if the services are explicitly excluded from the benefit plan
• C. allow D
• D. Patel to bill patients for services only if the services are considered to be medically necessary
• E. establish the guidelines used to determine if Arbor is the primary payor of benefits in a situation in which an Arbor plan member is covered by more than one health plan
• F. require D
• G. Patel to accept Arbor's payment as payment in full for medical services that he provides to Arbor plan members

Answer: D

NEW QUESTION 16

The following statements are about the delegation of network management activities from a health plan to another party. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:

• A. The NCQA requires a health plan to conduct all delegation oversight functions rather than delegating the responsibility for oversight to another entity.
• B. Credentialing and UM activities are the most frequently delegated functions, whereas delegation is less common for quality management (QM) and preventive health services.
• C. One reason that a health plan may choose to delegate a function is because the health plan's staff seeks external expertise for the delegated activity.
• D. When the health plan delegates authority for a function, it transfers the power to conduct the function on a day-to-day basis, as well as the ultimate accountability for the function.

Answer: D

NEW QUESTION 17

The following statement(s) can correctly be made about the TRICARE managed healthcare program of the U.S. Department of Defense.
* 1. Active-duty military personnel are automatically enrolled in TRICARE’s HMO option (TRICARE Prime).
* 2. Eligible family members and dependents can enroll in TRICARE Prime, the PPO plan (TRICARE Extra), or an indemnity plan (TRICARE Standard).

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

Answer: A

NEW QUESTION 18

The actual number of providers included in a provider network may be based on staffing ratios. Staffing ratios relate the number of

• A. Potential providers in a plan’s network to the number of individuals in the area to be served by the plan
• B. Providers in a plan’s network to the number of enrollees in the plan
• C. Providers outside a plan’s network to the number of providers in the plan’s network
• D. Support staff in a plan’s network to the number of medical practitioners in the plan’s network

Answer: B

NEW QUESTION 19

Grant Pelham is covered by both a workers’ compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.
The provider network that Shipwright uses to furnish services for its workers’ compensation program will most likely

• A. Emphasize primary care and consist mostly of generalists
• B. Focus treatment approaches on rapid recovery rather than cost
• C. Offer workers’ compensation beneficiaries the same types and levels of treatment that Shipwright’s traditional network furnishes to group health plan members
• D. Exempt participating providers from meeting standard credentialing requirements

Answer: B

NEW QUESTION 20

There are several approaches to providing Medicaid health plan. One such approach involves the use of organizations who contract with the state’s Medicaid agency to provide primary care as well as administrative services. These organizations are known as

• A. Enrollment brokers
• B. Primary care case managers (PCCMs)
• C. Certified medical assistants (CMAs)
• D. Prepaid health plans (PHPs)

Answer: B

NEW QUESTION 21
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