The Secret Of AHIP AHM-530 Testing Bible

NEW QUESTION 1

The following statements are about network management for behavioral healthcare (BH). Three of these statements are true and one statement is false. Select the answer choice containing the FALSE statement.

• A. Two measures of BH quality are patient satisfaction and clinical outcomes assessments.
• B. For a health plan, one argument in favor of contracting with a managed behavioral healthcare organization (MBHO) is that the health plan's members can gain faster access to BH care.
• C. In their contracts with health plans, managed behavioral healthcare organizations (MBHOs) usually receive delegated authority for network development and management.
• D. Health plans generally compensate managed behavioral healthcare organizations (MBHOs) on an FFS basis.

Answer: D

NEW QUESTION 2

One reimbursement method that health plans can use for hospitals is the ambulatory payment classifications (APCs) method. APCs bear a resemblance to the diagnosis-related groups (DRGs) method of reimbursement. However, when comparing APCs and DRGs, one of the primary differences between the two methods is that only the APC method

• A. is typically used for outpatient care
• B. assigns a single code for treatment
• C. applies to treatment received during an entire hospital stay
• D. is considered to be a retrospective payment system

Answer: A

NEW QUESTION 3

One true statement about the responsibilities of providers under typical provider contracts is that most provider contracts:

• A. include a clause which states that providers must maintain open communications with patients regarding appropriate treatment plans, unless the services are not covered by the member's health plan
• B. hold that the responsibility of the provider to deliver services is usually subject to theprovider's receipt of information regarding the eligibility of the member
• C. contain a gag clause or a gag rule
• D. include a clause that explicitly places the responsibility for medical care on the health plan rather than on the provider of medical services

Answer: B

NEW QUESTION 4

From the following answer choices, choose the type of clause or provision described in this situation.
The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.

• A. Cure provision
• B. Hold-harmless provision
• C. Evergreen clause
• D. Exculpation clause

Answer: C

NEW QUESTION 5

In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it

• A. Applies to group health insurance plans only
• B. Limits the length of a health plan’s pre-existing condition exclusion period for a previously covered individual to a maximum of six months after enrollment.
• C. Guarantees access to healthcare coverage for small businesses and previously covered individuals who meet specified eligibility requirements.
• D. Guarantees renewability of group and individual health coverage, provided the insureds are still in good health

Answer: C

NEW QUESTION 6

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.
If the Ellysium subacute care unit is typical of most hospital-based subacute skilled nursing units, then this unit could be used for patients who no longer need to be in the hospital’s acute care unit but who still require

• A. Daily medical care and monitoring
• B. Regular rehabilitative therapy
• C. Respiratory therapy
• D. All of the above

Answer: D

NEW QUESTION 7

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 8

The following statements are about fee-for-service (FFS) payment systems. Select the answer choice containing the correct statement:

• A. A discounted fee-for-service (DFFS) system is usually easier for a health plan to administer than is a fee schedule system.
• B. A case rate payment system offers providers an incentive to take an active role in managing cost and utilization.
• C. One reason that health plans use a relative value scale (RVS) payment system is that RVS values for cognitive services have traditionally been higher than the values for procedural services.
• D. One reason that health plans use a resource-based relative value scale (RBRVS) is that this system includes weighted unit values for all types of procedures.

Answer: B

NEW QUESTION 9

The sizes of the businesses in a market affect the types of health programs that are likely to be purchased. Compared to smaller employers (those with fewer than 100 employees), larger employers (those with more than 1,000 employees) are

• A. more likely to contract with indemnity health plans
• B. more likely to offer their employees a choice in health plans
• C. less likely to contract with health plans
• D. less likely to require a wide variety of benefits

Answer: B

NEW QUESTION 10

Martin Breslin, age 72 and permanently disabled, is classified as dually-eligible. This information indicates that Mr. Breslin qualifies for coverage by both

• A. Medicare and private indemnity insurance, and Medicare provides primary coverage
• B. Medicare and Medicaid, and Medicare provides primary coverage
• C. Medicaid and private indemnity insurance, and Medicaid provides primary coverage
• D. Medicare and Medicaid, and Medicaid provides primary coverage

Answer: B

NEW QUESTION 11

For this question, if answer choices (A) through C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Understanding the level of health plan penetration in a particular market can help a health plan determine which products are most appropriate for that market. Indicators of a mature health plan market include

• A. Areduction in the rate of growth in health plan premium levels
• B. Areduction in the level of outcomes management and improvement
• C. An increase in the rate of inpatient hospital utilization
• D. All of the above

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

Health plans can often reduce workers’ compensation costs by incorporating 24-hour coverage into their workers’ compensations programs. Twenty-four-hour coverage reduces costs by

• A. Maximizing the effects of cost shifting
• B. Eliminating the need for utilization management
• C. Requiring members to use separate points of entry for job-related and non-job related services
• D. Combining administrative services for workers’ compensation and non-workers’ compensation healthcare and disability coverage

Answer: D

NEW QUESTION 14

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 15

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.
The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan member for covered services is known as:

• A. Atermination with cause clause
• B. Ahold-harmless clause
• C. An indemnification clause
• D. Acorrective action clause

Answer: B

NEW QUESTION 16

CMS Medicare+Choice regulations include a provision that allows health plans to deny benefits for any services the health plan objects to on moral or religious grounds. The provision that exempts health plans from providing such services is known as

• A. a conscience protection exception
• B. a hold harmless clause
• C. a medical necessity determination
• D. an intermediate sanction

Answer: A

NEW QUESTION 17
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