AHM-530 | A Review Of Vivid AHM-530 Study Guides

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NEW QUESTION 1

Medicaid beneficiaries pose a challenge for health plans attempting to establish Medicaid provider networks. Compared to membership in commercial health plans, Medicaid enrollees typically

  • A. Require access to greater numbers of obstetricians and pediatricians
  • B. Have stronger relationships with primary care providers
  • C. Are less reliant on emergency rooms as a source of first-line care
  • D. Need fewer support and ancillary services

Answer: A

NEW QUESTION 2

One characteristic of the workers' compensation program is that:

  • A. workers' compensation coverage is available to all employees, regardless of their eligibility for health insurance coverage
  • B. indemnity benefits currently account for less than 10% of all workers' compensation benefits
  • C. workers' compensation programs in most states require eligible employees to obtain medical treatment only from members of a provider network
  • D. workers' compensation programs include deductibles and coinsurance requirements

Answer: A

NEW QUESTION 3

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 4

In 1996, the NAIC adopted a standard for health plan coverage of emergency services. This standard is based on a concept known as the:

  • A. Due process standard
  • B. Subrogation standard
  • C. Corrective action standard
  • D. Prudent layperson standard

Answer: D

NEW QUESTION 5

Lakesha Frazier, a member of a health plan in a rural area, had been experiencing heart palpitations and shortness of breath. Ms. Frazier’s primary care provider (PCP) referred her to a local hospital for an electrocardiogram. The results of the electrocardiogram were transmitted for diagnosis via high-speed data transmission to a heart specialist in a city 500 miles away. This information indicates that the results of Ms. Frazier’s electrocardiogram were transmitted using a communications system known as

  • A. Anarrow network
  • B. An integrated healthcare delivery system
  • C. Telemedicine
  • D. Customized networking

Answer: C

NEW QUESTION 6

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 7

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.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:

  • A. D
  • B. Enberg's young patients receive appropriate immunizations at the right ages
  • C. D
  • D. Enberg conforms to standards for prescribing controlled substances
  • E. The condition of one of D
  • F. Enberg's patients improved after the patient received medical treatment from D
  • G. Enberg
  • H. D
  • I. Enberg's procedures are adequate for ensuring patients' access to medical care

Answer: A

NEW QUESTION 8

Partial capitation is one common approach to capitation. One typical characteristic of partial capitation is that it:

  • A. Includes only primary care services
  • B. Covers such services as immunizations and laboratory tests
  • C. Can be used only if the provider's panel size is less than 50 providers
  • D. Covers such services as cardiology and orthopedics

Answer: A

NEW QUESTION 9

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 10

The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline.
Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn’s PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn’s dermatology services fund for the first quarter was $15,000. During the quarter, Autumn’s PCPs made 90 referrals, and 20 of these referrals were classified as complicated.
In determining the first quarter payment to dermatologists, Autumn would accurately calculate the value of each referral point to be

  • A. $111.11
  • B. $125.00
  • C. $150.00
  • D. $166.67

Answer: C

NEW QUESTION 11

Franklin Pitt selected a Medicare+Choice option under which he is covered by a catastrophic health insurance policy with a high annual deductible and a $6,000 out-of- pocket expense maximum. CMS pays the premiums for the insurance policy out of the usual Medicare+Choice payment and deposits any difference between the capitated amount and the policy premium in a savings account. Mr. Pitt can use funds in the savings account to pay qualified medical expenses not covered by his insurance policy. At the end of the benefit year, Mr. Pitt can carry any remaining funds into the next benefit year. The Medicare+Choice option Mr. Pitt selected is known as a

  • A. coordinate care plan (CCP)
  • B. medical savings account (MSA) plan
  • C. competitive medical plan (CMP)
  • D. Medicare Risk HMO program

Answer: B

NEW QUESTION 12

The following statement(s) can correctly be made about the Balanced Budget Act (BBA) of 1997:

  • A. The BBA requires Medicare+Choice organizations to be licensed as non-risk-bearing entities under federal law.
  • B. The Centers for Medicaid and Medicare Services (CMS) is responsible for implementing the BBA.
  • C. Both A and B
  • D. A only
  • E. B only
  • F. Neither A nor B

Answer: C

NEW QUESTION 13

The Avignon Company discontinued its contract with a traditional indemnity insurer and contracted exclusively with the Minaret Health Plan to provide the sole healthcare plan to Avignon’s employees. By agreeing to an exclusive contract with Minaret, Avignon has entered into a type of healthcare contract known as

  • A. a carrier guarantee arrangement
  • B. open access
  • C. total replacement coverage
  • D. selective contract coverage

Answer: C

NEW QUESTION 14

The following statements are about some of the issues surrounding the contractual responsibilities of health plans. Select the answer choice containing the correct statement.

  • A. Typically, health plans are required to pay completed claims within 10 days of submission.
  • B. Health plans typically are prohibited from examining the financial soundness of a self- funded employer plan that relies on the health plan to pay providers for services received by the plan’s members.
  • C. Patient delivery is one of the most significant factors that health plans consider when determining whether provider services should be reimbursed on a capitated or fee-for- service (FFS) basis.
  • D. Health plans require all providers to agree to an exclusive provider contract.

Answer: C

NEW QUESTION 15

With regard to the compensation of dental care providers in a managed dental care system, it is correct to state that, typically:

  • A. dental PPOs compensate dentists on a capitated basis
  • B. group model dental HMOs (DHMOs) compensate general dental practitioners on a salaried basis
  • C. independent practice association (IPA)-model dental HMOs (DHMOs) capitate general dental practitioners
  • D. staff model dental HMOs (DHMOs) compensate dentists on an FFS basis

Answer: C

NEW QUESTION 16
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