AHIP AHM-530 Free Practice Questions

NEW QUESTION 1

The following statement(s) can correctly be made about contracting and reimbursement of specialty care physicians (SCPs):

• A. Typically, a health plan should attempt to control utilization of SCPs before attempting to place these providers under a capitation arrangement.
• B. Forms of specialty physician reimbursement used by health plans include a retainer and a bundled case rate.
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: A

NEW QUESTION 2

The following statements are about the organization of network management functions of health plans. Select the answer choice containing the correct response:

• A. Compared to a large health plan, a small health plan typically has more integration among its network management activities and less specialization of roles.
• B. It is usually more efficient to have a large health plan's provider relations representatives located in the health plan's corporate headquarters rather than based in regional locations that are close to the provider offices the representatives cover.
• C. An health plan's provider relations representatives are usually responsible for conducting an initial orientation of providers and educating providers about health plan developments, rather than recruiting and assisting with the selection of new providers.
• D. In general, a health plan that uses a centralized approach for some of its network management activities should not use a decentralized approach for other network management activities.

Answer: A

NEW QUESTION 3

Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in

• A. Slower access to BH care for plan members
• B. Increased collaboration between BH providers and PCPs
• C. Fewer specialized BH services for plan members
• D. Decreased continuity of BH care for plan members

Answer: D

NEW QUESTION 4

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 Gladspell’s per diem contract with Ellysium is typical, then the per diem payment will cover such medical costs as

• A. Laboratory tests
• B. Respiratory therapy
• C. Semiprivate room and board
• D. Radiology services

Answer: C

NEW QUESTION 5

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement.
One important activity within the scope of network management is ensuring the quality of the health plan’s provider networks. A primary purpose of ________ is to review the clinical competence of a provider in order to determine whether the provider meets the health plan’s preestablished criteria for participation in the network.

• A. authorization
• B. provider relations
• C. credentialing
• D. utilization management

Answer: C

NEW QUESTION 6

By definition, a measure of the extent to which a health plan member can obtain necessary medical services in a timely manner is known as

• A. Network management
• B. Quality
• C. Cost-effectiveness
• D. Accessibility

Answer: D

NEW QUESTION 7

The BBA of 1997 specifies the ways in which a Medicare+Choice plan can establish and use provider networks. A Medicare+Choice plan that operates as a private fee for service (PFFS) plan is allowed to

• A. limit the size of its network to the number of providers necessary to meet the needs of its enrollees
• B. require providers to accept as payment in full an amount no greater than 115% of the Medicare payment rate
• C. refuse payment to non-network providers who submit claims for Medicare-coveredexpenses
• D. shift all risk for Medicare-covered services to network providers

Answer: B

NEW QUESTION 8

One true statement about the Medicaid program in the United States is that:

• A. The federal financial participation (FFP) in a state's Medicaid program ranges from 20% to 40% of the state's total Medicaid costs
• B. Medicaid regulations mandate specific minimum benefits, under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, for all Medicaid recipients younger than age 30
• C. The individual states have responsibility for administering the Medicaid program
• D. Non-disabled adults and children in low-income families account for the majority of direct Medicaid spending

Answer: C

NEW QUESTION 9

One type of fee schedule payment system assigns a weighted unit value for each medical procedure or service based on the cost and intensity of that service. Under this system, the unit values for procedural services are generally higher than the unit values for cognitive services. This system is known as a

• A. Wrap-around payment system
• B. Relative value scale (RVS) payment system
• C. Resource-based relative value scale (RBRVS) system
• D. Capped fee system

Answer: B

NEW QUESTION 10

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 11

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 12

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 13

The provider contract that Dr. Ted Dionne has with the Optimal Health Plan includes an arrangement that requires Dr. Dionne to notify Optimal if he contracts with another health plan at a rate that is lower than the rate offered to Optimal. Dr. Dionne must also offer this lower rate to Optimal. This information indicates that the provider contract includes a:

• A. Most-favored-nation arrangement
• B. Warranty arrangement
• C. Locum tenens arrangement
• D. Nesting arrangement

Answer: A

NEW QUESTION 14

Although a health plan is allowed to delegate many activities to outside sources, the National Committee for Quality Assurance (NCQA) has determined that some activities are not delegable.
These activities include

• A. evaluation of new medical technologies
• B. overseeing delegated medical records activities
• C. developing written statements of members’ rights and responsibilities
• D. all of the above

Answer: D

NEW QUESTION 15

Open panel health plans can contract with individual providers or with various provider groups when developing their networks. The following statements are about factors that an open panel health plan might consider in contracting with different types of provider organizations. Select the answer choice that contains the correct statement.

• A. One limitation of contracting with multispecialty groups is that a health plan obtains only specialty consultants, but not PCPs.
• B. One benefit to a health plan in contracting with an integrated delivery system (IDS) is the ability to have a network in rapid order and to enter into a new market or one that is already competitive.
• C. A health plan that contracts with an individual practice association (IPA) has a greater ability to select and deselect individual physicians than when contracting directly with the providers.
• D. A health plan that contracts with an IDS is able to eliminate the antitrust risk that exists when contracting with an IPA.

Answer: B

NEW QUESTION 16

Edward Patillo has established a Medicare+Choice medical savings account (MSA). This MSA will allow Mr. Patillo to:

• A. Carry over any money remaining in his MSA at the end of the benefit year to the next benefit year
• B. Make withdrawals at any time from the MSA, but only for medical expenses
• C. Obtain payment at 100% of the Medicare allowable payment for all Medicare-covered services he receives, without having to pay any deductibles or out-of-pocket expenses
• D. Make withdrawals from the MSA to meet qualified medical expenses that are not paid by his high-deductible health insurance policy, but these withdrawals are taxed as income to M
• E. Patillo

Answer: A

NEW QUESTION 17

During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider’s application. One true statement regarding this process is that the health plan

• A. has a legal right to access a prospective provider’s confidential medical records at any time
• B. must limit any evaluations of a prospective provider’s office to an assessment of quantitative factors, such as the number of double-booked appointments a physicianaccepts at the end of each day
• C. is prohibited by law from conducting primary verification of such data as a prospective provider’s scope of medical malpractice insurance coverage and federal tax identification number
• D. must complete the credentialing process before a provider signs the network contract or must include in the signed document a provision that the final contract is contingent upon the completion of the credentialing process

Answer: D

NEW QUESTION 18
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