Guaranteed AHIP AHM-540 Latest Exam Online

NEW QUESTION 1
Acute care refers to healthcare services for medical problems that

• A. are expected to continue for a minimum of 30 days
• B. are typically treated in a provider’s office or outpatient facility
• C. require prompt, intensive treatment by healthcare providers
• D. require low utilization of resources

Answer: C

NEW QUESTION 2
The paragraph below contains two pairs of terms 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.
Health plans use both internal and external standards to assess the quality of the services that they provide. (Internal / External) standards are based on information such as published industry-wide averages or best practices of recognized industry leaders. Health plans primarily rely on (internal / external) standards to evaluate healthcare services.

• A. Internal / internal
• B. Internal / external
• C. External / internal
• D. External / external

Answer: D

NEW QUESTION 3
The following statement(s) can correctly be made about performance measurement systems:
* 1.The most difficult purpose for a performance measurement system to address is to measure changes in outcomes caused by modifications in administrative or clinical treatment processes
* 2.A health plan needs different performance measurement systems to evaluate its administrative services and the clinical performance of its providers

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

Answer: C

NEW QUESTION 4
The following statements are about QAPI as it applies to Medicare+Choice plans and Medicaid health plan entities. Select the answer choice containing the correct statement.

• A. QAPI provides separate sets of standards for Medicaid MCEs and Medicare+Choice plans.
• B. Medicaid primary care case management (PCCM) programs are required to comply with all QAPI standards.
• C. QISMC standards for quality measurement and improvement apply only to clinical services delivered to Medicare and Medicaid enrollees.
• D. States that require Medicaid MCEs to comply with QAPI standards are considered to be in compliance with CMS quality assessment and improvement regulations.

Answer: D

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.
Well-crafted clinical practice guidelines (CPGs) can benefit healthcare delivery processes and outcomes by

• A. providing a framework for care while also allowing for patient-specific variations, based on physician judgment
• B. serving as a basis for evaluating whether providers are practicing in accordance with accepted standards
• C. focusing on the prevention or early detection of a particular condition
• D. all of the above

Answer: D

NEW QUESTION 6
The following statement(s) can correctly be made about the characteristics of peer review:
* 1.Peer review is applicable to either single episodes of care or to entire programs of care
* 2.Most peer review is conducted concurrently
* 3.Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services furnished to Medicare and Medicaid recipients enrolled in health plans

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

Answer: C

NEW QUESTION 7
Benchmarking is a quality improvement strategy used by some health plans. With regard to benchmarking, it is correct to say that

• A. cost-based benchmarking reveals why some areas of a health plan perform better or worse than comparable areas of other organizations
• B. diagnosis-related groups (DRGs) are a source of benchmarking data that describe individual procedures and cover both inpatient and outpatient care
• C. patient billing records provide a much more accurate account of procedure costs for benchmarking than do current procedural terminology (CPT) codes
• D. the focus of benchmarking for health plan has shifted from identifying the lowest cost practices to identifying best practices

Answer: D

NEW QUESTION 8
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 9
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 10
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 11
The following statement(s) can correctly be made about utilization guidelines:
* 1. When developing utilization guidelines, health plans balance evidence-based criteria with experience-based criteria
* 2. Utilization guidelines indicate when a UR nurse should refer a decision to a physician reviewer

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

Answer: A

NEW QUESTION 12
The Medicaid population can be divided into subgroups based on their relative size and the costs of providing benefits. From the answer choices below, select the response that correctly identifies the subgroups that represent the largest percentages of the total Medicaid population and of total Medicaid expenditures. Largest % of Medicaid Population- Largest % of Medicaid Expenditures-

• A. Largest % of Medicaid Population-dual eligibles Largest % of Medicaid Expenditures- children and low-income adults
• B. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for MedicareLargest % of Medicaid Expenditures-dual eligibles
• C. Largest % of Medicaid Population-children and low-income adults Largest % of Medicaid Expenditures-chronically ill or disabled individuals not eligible for Medicare
• D. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for Medicare Largest % of Medicaid Expenditures-children and low-income adults

Answer: C

NEW QUESTION 13
A health plan’s choice of structure measures, process measures, and outcome measures to evaluate performance depends in part on the scientific soundness of the measures. One approach that a health plan can use to enhance scientific soundness is stratification, which refers to the

• A. identification and removal of unusual cases, such as patients with contraindications to a particular treatment, from consideration
• B. statistical adjustment of outcome measures to account for differences in the severity of illness or the presence of other medical conditions
• C. specification of a target population for a procedure and the data collection and analysis methods to be used
• D. elimination of variation within a patient population by dividing the population into groups that are at a similar level of risk

Answer: D

NEW QUESTION 14
In order to be effective, a clinical pathway must improve quality and decrease costs.

• A. True
• B. False

Answer: B

NEW QUESTION 15
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 16
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 17
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