AHM-510 | A Review Of Virtual AHM-510 Dumps Questions

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NEW QUESTION 1
Nightingale Health Systems, a health plan, operates in a state that requires health plans to allow enrollees to visit obstetricians and gynecologists without a referral from a primary care provider. This information indicates that Nightingale must comply with a type of mandate known as a:

  • A. Direct access law
  • B. Scope-of-practice law
  • C. Provider contracting mandate
  • D. Physician incentive law

Answer: A

NEW QUESTION 2
Solvency standards for Medicare provider-sponsored organizations (PSOs) are divided into three parts: (1) the initial stage, (2) the ongoing stage, and (3) insolvency. In the initial stage, prior to CMS approval, a Medicare PSO typically must have a minimum net worth of

  • A. $750,000
  • B. $1,000,000
  • C. $1,500,000
  • D. $2,000,000

Answer: C

NEW QUESTION 3
The Tidewater Life and Health Insurance Company is owned by its policy owners, who are entitled to certain rights as owners of the company, and it issues both participating and nonparticipating insurance policies. Tidewater is considering converting to the type of company that is owned by individuals who purchase shares of the company's stock. Tidewater is incorporated under the laws of Illinois, but it conducts business in the Canadian provinces of Ontario and Manitoba.
Tidewater established the Diversified Corporation, which then acquired various subsidiary firms that produce unrelated products and services. Tidewater remains an independent corporation and continues to own Diversified and the subsidiaries. In order to create and maintain a common vision and goals among the subsidiaries, the management of Diversified makes decisions about strategic planning and budgeting for each of the businesses.
In creating Diversified, Tidewater formed the type of company known as

  • A. A mutual holding company
  • B. A spin-off company
  • C. An upstream holding company
  • D. A downstream holding company

Answer: D

NEW QUESTION 4
Health plans are allowed to appeal rules or regulations that affect them. Generally, the grounds for such appeals are limited either to procedural grounds or jurisdictional grounds. The Kabyle Health Plan appealed the following new regulations:
Appeal 1 - Kabyle objected to this regulation on the ground that this regulation is inconsistent with the law.
Appeal 2 - Kabyle objected to this regulation because it believed that the subject matter was outside the realm of issues that are legal for inclusion in the regulatory agency's regulations. Appeal 3 - Kabyle objected to the process by which this regulation was adopted.
Of these appeals, the ones that Kabyle appealed on jurisdictional grounds were

  • A. Appeals 1, 2, and 3
  • B. Appeals 1 and 2 only
  • C. Appeals 1 and 3 only
  • D. Appeals 2 and 3 only

Answer: B

NEW QUESTION 5
Regulators of health plans have set standards in a number of areas of plan operations. Requirements with which health plans must comply typically include

  • A. providing enrollees and prospective enrollees with detailed information about various aspects of health plan policies and operations
  • B. maintaining internal grievance and appeals processes to resolve enrollee complaints against the organization
  • C. maintaining quality assurance programs that reflect the plan's activities in monitoring quality
  • D. all of the above

Answer: D

NEW QUESTION 6
In the course of doing business, health plans conduct basic corporate transactions. For example, when a health plan engages in the corporate transaction known as aggressive sourcing, the health plan

  • A. Chooses to contract with vendors who provide specific functions that would otherwise be performed in-house, such as paying claims
  • B. Seeks to obtain the best deals from various vendors for equipment, supplies, and services such as telephones, overnight mail, computer hardware and software, and copy machines
  • C. Merges with one or more companies to form an entirely new company
  • D. Joins with one or more companies, but retains its autonomy and relies on the other companies to perform specific functions

Answer: B

NEW QUESTION 7
Any willing provider laws have their share of proponents and opponents. Arguments commonly made in opposition to any willing provider laws include

  • A. That such laws reduce the number of providers in a health plan's network
  • B. That such laws limit consumer choice to coverage options that are more costly than networkbased plans
  • C. That such laws encourage providers to offer discounts in exchange for patient volume
  • D. All of the above

Answer: B

NEW QUESTION 8
Directors on a health plan's board must demonstrate their compliance with three duties in all their decisions. Directors who exercise their duties in good faith and with the same degree of diligence and skill that an ordinary, reasonable person would be expected to display in the same situation are meeting the duty known as the

  • A. Duty of loyalty
  • B. Duty to supervise
  • C. Duty of care
  • D. Trustee duty

Answer: C

NEW QUESTION 9
In the paragraph below, a statement contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the statement. Then select the answer choice containing the two terms that you have chosen.
In the case of Pacificare of Oklahoma, Inc. v. Burrage, the U.S. Court of Appeals for the Tenth Circuit considered whether ERISA preempts medical malpractice claims against health plans based on certain liability theories. In this case, the Tenth Circuit court held that ERISA (should / should not) preempt a liability claim against an HMO for the malpractice of one of its primary care physicians, and therefore the HMO was subject to a claim of (subordinated / vicarious) liability.

  • A. Should / subordinated
  • B. Should / vicarious
  • C. Should not / subordinated
  • D. Should not / vicarious

Answer: D

NEW QUESTION 10
Several states have adopted clinical practice guidelines for treating workers' compensation injuries. Clinical practice guidelines can best be described as

  • A. Fee schedules that specify the maximum amount providers may charge for treating workers' compensation patients
  • B. A utilization management and quality management mechanism designed to aid providers in making decisions about the most appropriate course of treatment for a specific case
  • C. Detailed plans of medical treatment designed to facilitate a patient's return to the workplace
  • D. Payment practices that might technically violate the provisions of the anti-kickback statute but that will not be considered illegal and for which providers and health plans will not be subject to penalties

Answer: B

NEW QUESTION 11
Health maintenance organizations (HMOs) seeking federal qualification under the HMO Act of 1973 and its amendments must meet requirements in four basic operational areas. One operational requirement for qualification is that an HMO must

  • A. Ensure that at least 1/3 of its policy-making body is comprised of HMO members
  • B. Ensure that there is adequate representation of underserved communities on its policy-making body
  • C. Have an ongoing quality assurance program that meets the requirements of the Centers for Medicaid & Medicare Services (CMS), stresses health outcomes, and provides for review by health professionals
  • D. Test, safeguard, and promote quality of care by following detailed programmatic techniques that are explained in CMS's Federally Qualified HMO (FQHMO) Manual

Answer: C

NEW QUESTION 12
The Tidewater Life and Health Insurance Company is owned by its policy owners, who are entitled to certain rights as owners of the company, and it issues both participating and nonparticipating insurance policies. Tidewater is considering converting to the type of company that is owned by individuals who purchase shares of the company's stock. Tidewater is incorporated under the laws of Illinois, but it conducts business in the Canadian provinces of Ontario and Manitoba.
With regard to the state in which Tidewater is domiciled, it is correct to say that, from the perspective of both Ontario and Manitoba, Tidewater is considered to be the type of corporation known as:

  • A. A foreign corporation
  • B. An alien corporation
  • C. A sister corporation
  • D. A domestic corporation

Answer: B

NEW QUESTION 13
The government uses various tools within the realm of two broad categories of public policyallocative policies and regulatory policies. In the context of public policy, laws that fall into the
category of allocative policy include

  • A. The Balanced Budget Act (BBA) of 1997
  • B. The Health Insurance Portability and Accountability Act (HIPAA) of 1996
  • C. Laws affecting health plan quality oversight
  • D. Laws specifying procedures for health plan handling of consumer appeals and grievances

Answer: A

NEW QUESTION 14
Brighton Health Systems, Inc., a health plan, wants to modify its advertising and marketing materials to avoid liability risk under the principle of ostensible agency. One step that Brighton can take to reduce the likelihood of being liable for provider negligence under the theory of ostensible agency is to

  • A. Guarantee the quality of medical care provided to Brighton members
  • B. Use advertising materials which state that Brighton itself provides healthcare
  • C. Add disclaimers to advertising materials indicating that only physicians and not Brighton make medical decisions
  • D. Use advertising materials to characterize Brighton's role as providing physicians, hospitals, and other healthcare professionals rather than arranging for healthcare.

Answer: C

NEW QUESTION 15
There are several exceptions to the Ethics in Patient Referrals Act and its amendments (the Stark laws), which prohibit a physician from referring Medicare or Medicaid patients for certain designated services or supplies provided by entities in which the physician has a financial interest. Consider whether the situations described below qualify as exceptions to the Stark laws:
Situation A: Dr. Wong is a physician in the Marvel Health Plan's provider network and has a financial relationship with Marvel arising from the health plan's compensation for his services. Marvel is not a prepaid health plan.
Situation B: Dr. Ryder is a physician in the provider network of the Glen Health Plan, which is not a prepaid health plan. In situations of medical necessity, Dr. Ryder refers Glen patients to a physical therapy clinic that leases office space from him.
Situation C: Dr. Yost has a compensation arrangement with a health plan for providing health services under the Medicare+Choice program.
An arrangement that is exempt from the Stark laws is described in

  • A. All of these situations
  • B. Situations A and C only
  • C. Situation B only
  • D. Situation C only

Answer: D

NEW QUESTION 16
The following statements are about market conduct examinations of health plans. Select the answer choice that contains the correct statement.

  • A. Multistate examinations are not appropriate for financial examinations, because regulatory requirements concerning a health plan's financial condition tend to vary from state to state.
  • B. Market conduct examinations of a health plan's advertising and sales materials include comparing the advertising materials to the policies they advertise.
  • C. Once an examination report is provided to the state insurance department, a health plan is not given an opportunity to present a formal objection to the report.
  • D. In imposing sanctions on health plans, state insurance departments are required to follow federal sentencing guidelines.

Answer: B

NEW QUESTION 17
After conducting a business portfolio analysis, the Acorn Health Plan decided to pursue a harvest strategy with one of its strategic business units (SBUs)-Guest Behavioral Healthcare. By following a harvest strategy with Guest, Acorn most likely is seeking to

  • A. Maximize Guest's short-term earnings and cash flow
  • B. Increase Guest's market share
  • C. Maintain Guest's market position
  • D. Sacrifice immediate earnings in order to fund Guest's growth

Answer: A

NEW QUESTION 18
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