AHM-530 | How Many Questions Of AHM-530 Braindump

NEW QUESTION 1

The Aegean Health Plan delegated its utilization management (UM) program to the Silhouette IPA. Silhouette, in turn, transferred authority for case management to Brandon Health Services. In this situation, Brandon is best described as the

• A. delegator, and Aegean is ultimately responsible for Brandon’s performance
• B. delegator, and Silhouette is ultimately responsible for Brandon’s performance
• C. subdelegate, and Aegean is ultimately responsible for Brandon’s performance
• D. subdelegate, and Silhouette is ultimately responsible for Brandon’s performance

Answer: C

NEW QUESTION 2

A population’s demographic factors—such as income levels, age, gender, race, and ethnicity—can influence the design of provider networks serving that population. With respect to these demographic factors, it is correct to say that

• A. higher-income populations have a higher incidence of chronic illnesses than do lowerincome populations
• B. compared to other groups, young men are more likely to be attached to particular providers
• C. a population with a high proportion of women typically requires more providers than does a population that is predominantly male
• D. Health plans should not recognize, in either the design of networks or the evaluation of provider performance, racial and ethnic differences in the member population

Answer: C

NEW QUESTION 3

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 4

With regard to the compensation of dental care providers in a managed dental care system, it is correct to state that, typically:

• A. dental PPOs compensate dentists on a capitated basis
• B. group model dental HMOs (DHMOs) compensate general dental practitioners on a salaried basis
• C. independent practice association (IPA)-model dental HMOs (DHMOs) capitate general dental practitioners
• D. staff model dental HMOs (DHMOs) compensate dentists on an FFS basis

Answer: C

NEW QUESTION 5

The following statements can correctly be made about the advantages and disadvantages to an health plan of using the various delivery options for pharmacy services.

• A. A disadvantage of using open pharmacy networks is that the health plan’s control over costs is limited to setting reimbursement levels.
• B. An advantage of using performance-based systems is that they tend to increase participation in the health plan’s pharmacy network.
• C. A disadvantage of using customized pharmacy networks is that these networks typically can be implemented only in companies with fewer than 500 employees.
• D. All of these statements are correct.

Answer: A

NEW QUESTION 6

The following statements are about waivers and the Medicaid program. Select the answer choice containing the correct statement:

• A. The Balanced Budget Act (BBA) of 1997 eliminated the need for states to make formal applications for waivers.
• B. Section 1115 waivers allow states to bypass the Medicaid program's usual requirement of giving recipients complete freedom of choice in selecting providers.
• C. Title XVIII waivers allow states to mandate certain categories of Medicaid recipients to enroll in health plan plans.
• D. Section 1915(b) waivers allow states to establish demonstration projects in order to test new approaches to benefits and services provided by Medicaid.

Answer: A

NEW QUESTION 7

Before or during the orientation process, health plans generally provide new network providers with a provider manual. One of the primary purposes of the provider manual is to

• A. Provide a directory of contracted providers
• B. Help providers and their staffs develop methods of improving the operation of their practices
• C. Provide feedback to providers regarding their performance
• D. Reinforce and document contractual provisions

Answer: D

NEW QUESTION 8

A health plan that delegates designated credentialing activities to an NCQA-centered or a Commission/URAC-centered credentials verification organization (CVO) is exempt from the due-diligence oversight requirements specified in the NCQA credentialing standards for all
verification services for which the CVO has been certified:

• A. True
• B. False

Answer: A

NEW QUESTION 9

With regard to the laws and regulations on access and adequacy of provider networks, it can correctly be stated that:

• A. most access and adequacy guidelines relate to preferred provider organizations (PPOs) or managed indemnity products
• B. corporate practice of medicine laws require staff model HMOs to hire physicians directly,even if the physicians do not own the HMO
• C. any willing provider laws prevent a health plan from making exclusive or semi-exclusive arrangements with a provider or a group of providers
• D. the NAIC Managed Care Plan Network Adequacy Model Act requires states to use provider-enrollee ratios as the sole measure of network adequacy

Answer: C

NEW QUESTION 10

Dr. Eve Barlow is a specialist in the Amity Health Plan’s provider network. Dr. Barlow’s provider contract with Amity contains a typical most-favored-nation arrangement. The purpose of this arrangement is to

• A. Require D
• B. Barlow and Amity to use arbitration to resolve any disputes regarding the contract
• C. Specify that the contract is to be governed by the laws of the state in which Amity has its headquarters
• D. Require D
• E. Barlow to charge Amity her lowest rate for a medical service she has provided to an Amity plan member, even if the rate is lower than the price negotiated in the contract
• F. State that the contract creates an employment or agency relationship, rather than an independent contractor relationship, between D
• G. Barlow and Amity

Answer: C

NEW QUESTION 11

Decide whether the following statement is true or false:
The organizational structure of a health plan’s network management function often depends on the size and geographic scope of the health plan. With respect to the size of a health plan, it is correct to say that smaller health plans typically have less integration and more specialization of roles than do larger health plans.

• A. True
• B. False

Answer: B

NEW QUESTION 12

The Foxfire Health Plan, which has 20,000 members, contracts with dermatologists on a contact capitation basis. The contact capitation arrangement has the following features:
Foxfire distributes the money in the contact capitation fund once each quarter and the distribution is based on the point totals accumulated by each dermatologist.
Foxfire's per member per month (PMPM) capitation for dermatology services is $1.
The dermatologist receives 1 point for each new referral that is not classified as a complicated referral and 1.5 points for each new referral that is classified as complicated.
During the first quarter, Foxfire's PCPs made 450 referrals to dermatologists and 100 of these referrals were classified as complicated. One dermatologist, Dr. Shareef Rashad, received 42 of these referrals; 6 of his referrals were classified as complicated. Statements that can correctly be made about Foxfire's contact capitation arrangement include:

• A. that the value of each referral point for the first quarter was $120
• B. that the value of Foxfire's contact capitation fund for dermatologists for the first quarter was $20,000
• C. that the payment that Foxfire owed D
• D. Rashad for the first quarter was $6,120
• E. all of the above

Answer: A

NEW QUESTION 13

The following statements are about the negotiation process of provider contracting. Three of the statements are true and one of the statements is false. Select the answer choice containing the FALSE statement.

• A. While preparing for negotiations, the health plan usually sends the provider an application to join the provider network, a list of credentialing requirements, and a copy of the proposed provider contract, which may or may not include the proposed reimbursement schedule.
• B. In general, the ideal negotiating style for provider contracting is a collaborative approach.
• C. Typically, the health plan and the provider negotiate the reimbursement arrangement between the parties before they negotiate the scope of services and the contract language.
• D. The actual signing of the provider contract typically takes place after negotiations are completed.

Answer: C

NEW QUESTION 14

In contracting with providers, a health plan can use a closed panel or open panel approach. One statement that can correctly be made about an open panel health plan is that the participating providers

• A. must be employees of the health plan, rather than independent contractors
• B. are prohibited from seeing patients who are members of other health plans
• C. typically operate out of their own offices
• D. operate according to their own standards of care, rather than standards of care established by the health plan

Answer: C

NEW QUESTION 15

The provider contract that Dr. Lorena Chau has with the Fiesta Health Plan includes an evergreen clause. The purpose of this clause is to:

• A. Allow Fiesta to change or amend the contract without D
• B. Chau's approval as long as the modifications are made in order to comply with new legal and regulatory requirements
• C. Prohibit D
• D. Chau from encouraging her patients to switch from Fiesta to another health plan
• E. Prohibit D
• F. Chau from encouraging her patients to switch from Fiesta to another health plan
• G. Assure that D
• H. Chau provides Fiesta members with healthcare services in a timely manner appropriate to the member's medical condition

Answer: C

NEW QUESTION 16

Health plans are required to follow several regulations and guidelines regarding the access and adequacy of their provider networks. The Federal Employee Health Benefits Program (FEHBP) regulations, for example, require that health plans

• A. Allow members direct access to OB/GYN services
• B. Allow members direct access to prescription drug services
• C. Provide access to Title X family-planning clinics
• D. Provide average office waiting times of no more than 30 minutes for appointments with plan providers

Answer: D

NEW QUESTION 17

The Elizabethan Health Plan uses a direct referral program, which means that

• A. PCPs in Elizabethan’s network can make most referrals without obtaining prior authorization from Elizabethan
• B. PCPs in Elizabethan’s network must always refer plan members to other specialists within the network
• C. Elizabethan’s plan members can bypass the PCP and obtain medical services from a specialist without a referral
• D. Elizabethan’s plan members must obtain referrals directly from Elizabethan

Answer: A

NEW QUESTION 18

The Blanchette Health Plan uses a method of claims submission that allows its providers to submit claims directly to Blanchette through a computer application-to-application exchange of claims using a standard data format. This information indicates that Blanchette allows its providers to submit claims using technology known as

• A. Telemedicine
• B. An electronic referral system
• C. Electronic data interchange
• D. Encounter reporting

Answer: C

NEW QUESTION 19

The following statement(s) can correctly be made about the Balanced Budget Act (BBA) of 1997:

• A. The BBA requires Medicare+Choice organizations to be licensed as non-risk-bearing entities under federal law.
• B. The Centers for Medicaid and Medicare Services (CMS) is responsible for implementing the BBA.
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: C

NEW QUESTION 20

Some states have enacted any willing provider laws. From the perspective of the health plan industry, one drawback of any willing provider laws is that they often result in a reduction of a plan’s

• A. Premium rates
• B. Ability to monitor utilization
• C. Number of primary care providers (PCPs)
• D. Number of specialists and ancillary providers

Answer: B

NEW QUESTION 21
......