AHM-540 | What Simulation AHM-540 Test Question Is

NEW QUESTION 1
Determine whether the following statement is true or false:
The delegation of medical management functions to providers can occur without the transfer of financial risk.

• A. True
• B. False

Answer: A

NEW QUESTION 2
The delivery of quality, cost-effective healthcare is a primary goal of both group healthcare and workers’ compensation programs. One difference between group healthcare and workers’ compensation is that workers’ compensation

• A. provides health and disability benefits to employees injured on the job only if the employer is at fault for the injury
• B. provides coverage for a variety of direct and indirect healthcare, disability, and workplace costs
• C. manages costs by including employee cost-sharing features in its benefit design
• D. places limits on benefits by restricting the amount of benefit payments or the number of covered hospital days or provider office visits

Answer: B

NEW QUESTION 3
Breanna Osborn is a case manager for a regional health plan. One component of Ms. Osborn’s job is the collection and evaluation of medical, financial, social, and psychosocial information about a member’s situation. This component of Ms. Osborn’s job is known as

• A. case identification
• B. case management planning
• C. healthcare coordination
• D. case assessment

Answer: D

NEW QUESTION 4
The following statement(s) can correctly be made about the use of screening for secondary prevention:
* 1. Screening activities may involve specialty care providers as well as primary care providers (PCPs) and the health plan
* 2. Secondary prevention often results in more utilization of services immediately following screening
* 3. Screening focuses on members who have not experienced any symptoms of a particular illness

• A. All of the above
• B. 1 and 3 only
• C. 2 and 3 only
• D. 1 only

Answer: A

NEW QUESTION 5
Federal laws, such as the Employee Retirement Income Security Act (ERISA), the Balanced Budget Act (BBA) of 1997, and the Health Insurance Portability and Accountability Act (HIPAA), have affected medical management activities by health plans. Consider the following provisions of federal regulations:
Provision 1—Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered treatment and does not allow health plan members to obtain compensatory or punitive damages
Provision 2—Establishes electronic data security standards, which define the security measures that healthcare organizations must take to protect the confidentiality of electronically stored and transmitted patient information From the answer choices below, select the response that correctly identifies the federal laws that include Provision 1 and Provision 2, respectively.

• A. Provision 1- ERISA Provision 2- HIPAA
• B. Provision 1- HIPAA Provision 2- ERISA
• C. Provision 1- BBA of 1997 Provision 2- HIPAA
• D. Provision 1- ERISA Provision 2- BBA of 1997

Answer: A

NEW QUESTION 6
To see that utilization guidelines are consistently applied, UR programs rely on authorization systems. Determine whether the following statement about authorization systems is true or false:
Only physicians can make nonauthorization decisions based on medical necessity.

• A. True
• B. False

Answer: A

NEW QUESTION 7
Determine whether the following statement is true or false:
Immunization programs are a direct means of reducing health plan members’ needs for healthcare services and are typically cost-effective.

• A. True
• B. False

Answer: A

NEW QUESTION 8
To measure performance for quality management, health plans collect and analyze three types of data: financial data, clinical data, and customer satisfaction data. The following statement(s) can correctly be made about the sources of clinical data:
* 1.Patient surveys are the most widely used source of disease-specific clinical information
* 2.Outcomes research studies sponsored by academic institutions and professional organizations have limited usefulness for particular health plans or individual providers
* 3.The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys address both physical and mental health status

• A. All of the above
• B. 1 and 2 only
• C. 2 and 3 only
• D. 3 only

Answer: C

NEW QUESTION 9
Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located at a military installation. Ms. Wilson serves as a primary point of contact between enrollees and the TRICARE system and answers enrollees’ questions about plan options, eligibility, provider selection, and claims. This information indicates that Ms. Wilson serves as a

• A. lead agent
• B. beneficiary services representative
• C. health plan support contractor
• D. primary care manager (PCM)

Answer: B

NEW QUESTION 10
The Fairview Health Plan uses a dual database approach to integrate information needed for its disease management program. This information indicates that Fairview uses an information management system that

• A. combines all existing information from all data sources into a single comprehensive system
• B. connects multiple databases with a central interface engine that acts as an information clearinghouse
• C. provides an outside vendor with pertinent data that the vendor compiles into an integrated database
• D. creates a separate database that pulls pertinent information from the health plan’s claims database, formats the information for easy analysis, and stores it in the separate database

Answer: D

NEW QUESTION 11
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.
The Millway Health Plan received a 15% reduction in the price of a particular pharmaceutical based on the volume of the drug Millway purchased from the manufacturer. This reduction in price is an example of a (rebate / price discount) and (is / is not) dependent on actual provider prescribing patterns.

• A. rebate / is
• B. rebate / is not
• C. price discount / is
• D. price discount / is not

Answer: D

NEW QUESTION 12
Performance variance can be classified as either common cause variance or special cause variance. The following statement(s) can correctly be made about special cause variance:
* 1. Inadequate staffing levels, employee errors, and equipment malfunctions are examples of special cause variance
* 2. Special cause variance is typically more difficult to detect and correct than is common cause variance

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

Answer: B

NEW QUESTION 13
When analyzing and applying HRA results, the Multistate Health Plan noted sampling bias. This information indicates that the HRA results

• A. do not accurately depict the characteristics of the Multistate member population under study because of errors in data collection
• B. are more accurate for individual Multistate members than they are for the total population
• C. cannot be stated in numerical terms
• D. indicate variation in the number, types, and severity of behavioral risks presented by Multistate’s members

Answer: A

NEW QUESTION 14
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Ways that workers’ compensation health plans can help control the costs of job-related injuries and illnesses include

• A. applying strict definitions of medical necessity
• B. developing prevention and recovery programs
• C. applying out-of-network benefit reductions
• D. all of the above

Answer: B

NEW QUESTION 15
Increased demands for performance information have resulted in the development of various health plan report cards. With respect to most of the report cards currently available, it is correct to say

• A. that they are focused primarily on health maintenance organization (HMO) plans
• B. that they are based on data collected for the Health Plan Employer Data and Information Set (HEDIS) 3.0
• C. that they are used to rank the performance of various health plans
• D. all of the above

Answer: D

NEW QUESTION 16
This agency oversees fraud and abuse matters as they relate to medical management.

• A. Health Resources and Services Administration (HRSA)
• B. Office of Personnel Management (OPM)
• C. Department of Health and Human Services (HHS)
• D. Department of Justice (DOJ)

Answer: D

NEW QUESTION 17
......