AHM-540 | The Secret Of AHIP AHM-540 Question

NEW QUESTION 1
Nilay Sharma suffered a small wound while working in his yard and was taken to a local hospital for treatment. A triage nurse at the hospital evaluated Mr. Sharma’s condition and directed him to an outpatient unit in the hospital where a physician assistant examined, cleaned, and sutured the wound. Mr. Sharma returned home following treatment. The care Mr. Sharma received at the hospital is an example of the type of care known as

• A. specialty referral
• B. primary prevention
• C. urgent care
• D. emergency care

Answer: C

NEW QUESTION 2
Since its inception, Medicare has undergone a number of changes because of legal and regulatory action. One result of the Balanced Budget Act (BBA) of 1997 has been to

• A. expand Medicare benefits by mandating coverage for certain preventive services
• B. reduce the number of organizations that can deliver covered services
• C. encourage growth of managed Medicare programs in all markets
• D. increase the number of “zero premium” plans available to Medicare beneficiaries

Answer: A

NEW QUESTION 3
CMS has developed two prototype programs—Programs of All-inclusive Care for the Elderly (PACE) and the Social Health Maintenance Organization (SHMO) demonstration project—to deliver healthcare services to Medicare beneficiaries. From the answer choices below, select the response that correctly identifies the features of these programs.

• A. PACE-annual limits on benefits for nursing home and community-based care SHMO-no limits on long-term care benefits
• B. PACE-provide long-term care only SHMO-provide acute and long-term care
• C. PACE-enrollees must be age 65 or older SHMO-enrollees must be age 55 or older
• D. PACE-enrollment open to nursing home certifiable Medicare beneficiaries only SHMO- enrollment open to all Medicare beneficiaries

Answer: D

NEW QUESTION 4
Health plans communicate proposed performance changes through action statements. Select the answer choice containing an action statement that includes all of the required elements.

• A. The proportion of adult members who are screened for hypertension will increase by ten percent.
• B. Primary care providers (PCPs) will increase the proportion of children under the age of two who are up-to-date on immunizations by seven percent within one year.
• C. The QM program director will evaluate the level of provider compliance with clinicalpractice guidelines (CPGs).
• D. The disease management program director will increase participation by asthmatic children in the health plan’s pediatric asthma disease management program.

Answer: B

NEW QUESTION 5
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say

• A. that the construction of a data warehouse is quick and simple
• B. that a data warehouse addresses the problems associated with multiple data management systems
• C. that a data warehouse stores only current data
• D. all of the above

Answer: B

NEW QUESTION 6
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
Each quality standard used by a health plan is associated with quality indicators. A ______ indicator is a form of aggregate data indicator that produces results that fit within a specified range, such as the length of time to schedule an appointment.

• A. yes/no
• B. sentinel event
• C. discrete variable
• D. continuous variable

Answer: D

NEW QUESTION 7
The nature of behavioral healthcare creates unique medical management challenges for health plans. One method health plans have used to support the delivery of appropriate services in a cost-effective manner is to

• A. remove behavioral healthcare services from the primary care setting
• B. shift behavioral healthcare from acute inpatient settings to alternative settings when feasible
• C. reserve the use of psychotherapy for treatment of those conditions that persist over long periods of time or for the life of the patient
• D. offer the same level of compensation to all of the professional disciplines that provide behavioral healthcare services to plan members

Answer: B

NEW QUESTION 8
Selene Varga is participating in her health plan’s disease management program for congestive heart failure. Ms. Varga’s health status is regularly monitored and managed by a licensed nurse who visits Ms. Varga at her home to administer treatment and assess the need for changes in Ms. Varga’s overall care plan. This information indicates that Ms. Varga is participating in the type of disease management program known as a

• A. coordinated outreach model program
• B. case management model program
• C. hub-and-spoke model program
• D. group clinic model program

Answer: B

NEW QUESTION 9
Health plans that choose to contract with external organizations for pharmacy services typically contract with pharmacy benefit managers (PBMs). Functions that a PBM typically performs for a health plan include
* 1.Managing the costs of prescription drugs
* 2.Promoting efficient and safe drug use
* 3.Determining the health plan’s internal management responsibilities for pharmacy services

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

Answer: B

NEW QUESTION 10
A health plan’s coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions:
* 1. In case of conflict between the purchaser contract and a health plan’s medical policy or benefits administration policy, the contract takes precedence
* 2. Purchaser contracts commonly exclude custodial care from their coverage of services and supplies
* 3. All of the criteria for coverage decisions must be included in the purchaser contract

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

Answer: B

NEW QUESTION 11
The Harbor Health Plan’s formulary policy encourages network pharmacists who are asked to fill a prescription for a costly, brand-name drug to dispense a different chemical entity within the same drug class in order to reduce costs. This type of drug substitution is referred to as

• A. generic substitution, and prescriber approval is not required
• B. generic substitution, and prescriber approval is always required
• C. therapeutic substitution, and prescriber approval is not required
• D. therapeutic substitution, and prescriber approval is always required

Answer: D

NEW QUESTION 12
Among this agency’s accreditation programs are accreditation for preferred provider organizations (PPOs), health plan call centers, and case management organizations. This agency classifies its standards as either “shall” standards or “should” standards.

• A. American Accreditation HealthCare Commission/URAC (URAC)
• B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• C. Community Health Accreditation Program (CHAP)
• D. National Committee for Quality Assurance (NCQA)

Answer: A

NEW QUESTION 13
Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.
The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Greenhouse’s prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).

• A. open / mandatory
• B. open / voluntary
• C. closed / mandatory
• D. closed / voluntary

Answer: C

NEW QUESTION 14
The Carlyle Health Plan uses the following clinical outcome measures to evaluate its diabetes and asthma disease management programs:
Measure 1: The percentage of diabetic patients who receive foot exams from their providers according to the program’s recommended guidelines Measure 2: The number of asthma patients who visited emergency departments for acute asthma attacks
From the answer choices below, select the response that correctly identifies whether these measures are true outcome measures or intermediate outcome measures. Measure 1- Measure 2-

• A. Measure 1-true outcome measure Measure 2-true outcome measure
• B. Measure 1-true outcome measure Measure 2-intermediate outcome measure
• C. Measure 1-intermediate outcome measure Measure 2-true outcome measure
• D. Measure 1-intermediate outcome measure Measure 2-intermediate outcome measure

Answer: C

NEW QUESTION 15
Comorbidity can have a significant impact on the effective implementation of disease management programs. Comorbidity can correctly be defined as the

• A. degree to which the progression of a disease or condition is understood
• B. prevalence or rate of a sickness or injury within a given population
• C. degree of severity of a particular disease or condition
• D. presence of a chronic condition or added complication other than the condition that requires medical treatment

Answer: D

NEW QUESTION 16
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 two terms or phrases that you have selected.
The process for collecting and analyzing data differs for quality assessment (QA) and quality improvement (QI). For QA, data collection focuses on (objective / both objective and subjective) data, and data analysis identifies the (degree / cause) of variance.

• A. objective / degree
• B. objective / cause
• C. both objective and subjective / degree
• D. both objective and subjective / cause

Answer: A

NEW QUESTION 17
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