AHIP AHM-540 Free Practice Questions

NEW QUESTION 1
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 2
Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services

• A. must be offered as separate supplemental benefits or separate products
• B. lack clinical trials to evaluate their safety and effectiveness
• C. are not covered by state or federal consumer protection statutes
• D. focus on a specific illness, injury, or symptom rather than on the whole body

Answer: B

NEW QUESTION 3
One of the steps in drug utilization review (DUR) is defining optimal drug use, which can be accomplished by applying diagnosis criteria and drug-specific criteria. Drug-specific criteria are standards that identify the

• A. appropriate dosages, duration of treatment, and other elements related to the use of a particular drug
• B. actual prescribing and dispensing patterns for a particular drug
• C. types of diseases, conditions, or patients for which a drug should be used
• D. cost-effectiveness of all possible drug treatments for a particular condition

Answer: A

NEW QUESTION 4
Administrative action plans are used when performance problems or opportunities are related to the way the organization itself operates. The following statement(s) can correctly be made about administrative action plans:
* 1.Administrative action plans allow health plans to coordinate management activities
* 2.One function of administrative action plans is to integrate service across all levels of the organization
* 3.Administrative action plans are designed to improve outcomes by helping plan members assume responsibility for their own health

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

Answer: B

NEW QUESTION 5
The Fairview Health Plan uses a dual database approach to integrate information needed for its disease management program. This information indicates that Fairview uses an information management system that

• A. combines all existing information from all data sources into a single comprehensive system
• B. connects multiple databases with a central interface engine that acts as an information clearinghouse
• C. provides an outside vendor with pertinent data that the vendor compiles into an integrated database
• D. creates a separate database that pulls pertinent information from the health plan’s claims database, formats the information for easy analysis, and stores it in the separate database

Answer: D

NEW QUESTION 6
The following statements are about the use of hospitalists to manage inpatient care. Select the answer choice containing the correct statement.

• A. A patient who has been transferred to a hospitalist for management of inpatient care usually continues to receive care from the hospitalist after discharge.
• B. Hospitalists are used primarily to manage care for obstetric, pediatric, and oncology patients.
• C. In order to serve as a hospitalist, a physician must have a background in critical care medicine.
• D. Hospitalists typically spend at least one-quarter of their time in a hospital setting.

Answer: D

NEW QUESTION 7
The following statements are about the characteristics of a utilization review (UR) program. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. A primary goal of UR is to address practice variations through the application of uniform standards and guidelines.
• B. UR evaluates whether the services recommended by a member’s provider are covered under the benefit plan.
• C. UR recommends the procedures that providers should perform for plan members.
• D. A health plan’s UR program is usually subject to review and approval by the state insurance and/or health departments.

Answer: C

NEW QUESTION 8
DUR can be conducted prospectively, concurrently, or retrospectively. One true statement about prospective DUR is that it

• A. involves periodic audits of the medical records of a certain group of patients
• B. is based on historical data
• C. focuses on the drug therapy for a single patient rather than overall usage patterns
• D. is conducted by physicians, without input from pharmacists

Answer: C

NEW QUESTION 9
Health plans conduct evaluations on the efficiency and effectiveness of their quality improvement activities. With regard to the effectiveness of quality improvement plans, it is correct to say that

• A. effectiveness is the relationship between what the organization puts into an improvement plan and what it gets out of the plan
• B. effectiveness is measured by reviewing outcomes to determine the accuracy or appropriateness of the strategy and the adequacy of resources allocated to that strategy
• C. the effectiveness of an action plan is typically measured with a concurrent evaluation
• D. an evaluation of plan effectiveness produces one of two results: the plan either (a) achieved the desired outcomes or (b) did not achieve the desired outcomes and is unlikely to do so under current conditions

Answer: B

NEW QUESTION 10
Economically, health plans cannot provide coverage for every drug available from every manufacturer. As a result, purchaser contracts often include provisions specifying that certain drugs or drug types will not be covered. These provisions are referred to as

• A. limitations
• B. exceptions
• C. exclusions
• D. drug edits

Answer: C

NEW QUESTION 11
One method of transferring the information in electronic medical records (EMRs) is through a health information network (HIN). The following statements are about HINs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. A HIN may afford a health plan better measurements of outcomes and provider performance.
• B. The use of a HIN typically increases a health plan’s exposure to liability for poor care.
• C. Most HINs are Internet-based rather than built on proprietary computer networks.
• D. Currently, the majority of health plans do not have HINs that are capable of transferring medical records among their network providers.

Answer: B

NEW QUESTION 12
Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans typically use home healthcare include
* 1. The period prior to a hospital admission
* 2. The period following discharge from a hospital

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

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
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 15
Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide should Mr. Farrell become incapacitated.
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Decisions regarding Mr. Farrell’s end-of-life care are legally the right and responsibility of

• A. M
• B. Farrell and his family
• C. M
• D. Farrell’s physician
• E. M
• F. Farrell’s health plan
• G. All of the above

Answer: A

NEW QUESTION 16
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
The QAPI (Quality Assessment Performance Improvement Program) is a Centers for Medicaid and Medicare Services (CMS) initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standards apply to

• A. standard medical-surgical services
• B. mental health and substance abuse services
• C. services offered to Medicare enrollees as optional supplementary benefits
• D. all of the above

Answer: D

NEW QUESTION 17
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