How Many Questions Of AHM-530 Preparation

NEW QUESTION 1

The Medicaid program subsidizes indigent care through payments to disproportionate share hospitals (DSHs). The Preamble Hospital is a DSH. As a DSH, Preamble most likely:

• A. Receives financial assistance from the federal government but not a state government.
• B. Is at a higher risk of operating at a loss than are most other hospitals.
• C. Receives no payments directly from Medicaid for services rendered but rather receives a portion of the capitation payment that Medicaid makes to the health plans with which Preamble contracts.
• D. Is eligible for capitation rates that are significantly higher than the FFS average for all covered Medicaid services.

Answer: B

NEW QUESTION 2

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 3

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 4

Salvatore Arris is a member of the Crescent Health Plan, which provides its members with a full range of medical services through its provider network. After suffering from debilitating headaches for several days, Mr. Arris made an appointment to see Neal Prater, a physician’s assistant in the Crescent network who provides primary care under the supervision of physician Dr. Anne Hunt. Mr. Prater referred Mr. Arris to Dr. Ginger Chen, an ophthalmologist, who determined that Mr. Arris’ symptoms were indicative of migraine headaches. Dr. Chen prescribed medicine for Mr. Arris, and Mr. Arris had the prescription filled at a pharmacy with which Crescent has contracted. The pharmacist, Steven Tucker, advised Mr. Arris to take the medicine with food or milk. In this situation, the person who functioned as an ancillary service provider is

• A. M
• B. Prater
• C. D
• D. Hunt
• E. D
• F. Chen
• G. M
• H. Tucker

Answer: D

NEW QUESTION 5

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 6

The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 allowed competitive medical plans (CMPs) to participate in the Medicare program on a risk basis. Under the terms of Medicare risk contracts, CMPs were required to deliver all medically necessary Medicare- covered services in return for a

• A. fixed monthly capitation payment from CMS
• B. fee-for-service payment from the appropriate state Medicare agency
• C. mandatory premium paid by plan enrollees
• D. fee equal to twice the actuarial value of the Medicare deductible and coinsurance paid by plan enrollees

Answer: A

NEW QUESTION 7

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 8

The National Association of Insurance Commissioners (NAIC) Managed Care Plan Network Adequacy Model Act defines specific adequacy and accessibility standards that health plans must meet. In addition, the Model Act requires health plans to

• A. Hold plan members responsible for unreimbursed charges or unpaid claims
• B. Allow providers to develop their own standards of care
• C. Adhere to specified disclosure requirements related to provider contract termination
• D. File written access plans and sample contracts with the Centers for Medicaid and Medicare Services (CMS)

Answer: C

NEW QUESTION 9

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 10

Lakesha Frazier, a member of a health plan in a rural area, had been experiencing heart palpitations and shortness of breath. Ms. Frazier’s primary care provider (PCP) referred her to a local hospital for an electrocardiogram. The results of the electrocardiogram were transmitted for diagnosis via high-speed data transmission to a heart specialist in a city 500 miles away. This information indicates that the results of Ms. Frazier’s electrocardiogram were transmitted using a communications system known as

• A. Anarrow network
• B. An integrated healthcare delivery system
• C. Telemedicine
• D. Customized networking

Answer: C

NEW QUESTION 11

If a member of the Green Health Plan reasonably believes that a provider in Green's provider network was acting as Green's employee or agent while providing negligent care, then the member may have cause to bring action against the health plan. This legal concept is known as vicarious liability. Steps that Green can take to reduce its exposure to vicarious liability claims include:

• A. Placing restrictions on provider-member communication involving treatment decisions.
• B. Implementing risk management and quality assurance programs for its provider network.
• C. Including in its provider agreements and marketing and membership literature a statement that members of the Green provider network are not independent contractors.
• D. All of the above.

Answer: B

NEW QUESTION 12

The vision benefits offered by the Omni Health Plan include clinical eye care only. The following statements describe vision care received by Omni plan members:
•Brian Pollard received treatment for a torn retina he suffered as a result of an accident
•Angelica Herrera received a general eye examination to test her vision
•Megan Holtz received medical services for glaucoma
Of these medical services, the ones that most likely would be covered by Omni's vision coverage would be the services received by:

• A. M
• B. Pollard, M
• C. Herrera, and M
• D. Holtz
• E. M
• F. Pollard and M
• G. Herrera only
• H. M
• I. Pollard and M
• J. Holtz only
• K. M
• L. Herrera and M
• M. Holtz only

Answer: C

NEW QUESTION 13

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 14

In open panel contracting, there are several types of delivery systems. One such delivery system is the faculty practice plan (FPP). One likely result that a health plan will experience by contracting with an FPP is that the health plan will

• A. be able to select most of the physicians in the FPP
• B. achieve the highest level of cost effectiveness possible
• C. experience limited control over utilization
• D. achieve the most effective case management possible

Answer: C

NEW QUESTION 15

The provider contracts that the Indigo Health Plan has with its providers include a clause which states that Indigo's denial of payment for a certain medical procedure does not constitute a medical opinion and is not intended to interfere with the provider-patient relationship. This information indicates that Indigo's provider contracts include:

• A. A business confidentiality clause.
• B. A scope of services clause.
• C. An informed refusal clause.
• D. An exculpation clause.

Answer: D

NEW QUESTION 16

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service
(DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:

• A. D
• B. Enberg's young patients receive appropriate immunizations at the right ages
• C. D
• D. Enberg's young patients receive appropriate immunizations at the right ages
• E. The condition of one of D
• F. Enberg's patients improved after the patient received medical treatment from D
• G. Enberg
• H. D
• I. Enberg's procedures are adequate for ensuring patients' access to medical care

Answer: A

NEW QUESTION 17
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