AHM-540 | Abreast Of The Times AHM-540 Exam Answers For Medical Management Certification

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NEW QUESTION 1
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 2
Occasionally, employers combine workers’ compensation, group healthcare, and disability programs into an integrated product known as 24-hour coverage. One true statement about 24-hour coverage is that it typically

  • A. increases administrative costs
  • B. requires plans to maintain separate databases of patient care information
  • C. exempts plans from complying with state workers’ compensation regulations
  • D. allows plans to apply disability management and return-to-work techniques to nonoccupational conditions

Answer: D

NEW QUESTION 3
Determine whether the following statement is true or false: Participation in disease management programs is currently voluntary.

  • A. True
  • B. False

Answer: A

NEW QUESTION 4
Step-therapy is a form of prior authorization that reserves the use of more expensive medications for cases in which the use of less expensive medications has been unsuccessful. Step-therapy is appropriate for situations in which
* 1.A significant percentage of those treated with the initial therapy will require the second therapy
* 2.The delay created when a patient moves from one therapy to the next therapy will not cause serious or permanent effects

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

Answer: C

NEW QUESTION 5
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
To manage the delivery of healthcare services to their members, health plans use clinical practice parameters. _________ is the type of clinical practice parameter that a health plan uses to make coverage decisions concerning medical necessity and appropriateness.

  • A. A clinical practice guideline (CPG)
  • B. Medical policy
  • C. Benefits administration policy
  • D. A standard of care

Answer: B

NEW QUESTION 6
Recent laws and regulations have established new requirements for Medicaid eligibility. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 affected Medicaid eligibility by

  • A. severing the link between Medicaid and public assistance
  • B. eliminating the need for applications for Medicaid and public assistance
  • C. allowing states to provide healthcare benefits to groups outside the traditional Medicaid population
  • D. providing supplemental funding for dual eligibles in the form of five-year block grants

Answer: A

NEW QUESTION 7
The following statements are about health plans’ use of electronic data interchange (EDI). Three of the statements are true and one is false. Select the answer choice containing the FALSE ALSE statement.

  • A. One advantage of EDI over manual data management systems is improved data integrity.
  • B. EDI may use the Internet as the communication link between the participating parties.
  • C. EDI involves back-and-forth exchanges of information concerning individual transactions.
  • D. The data format for EDI is agreed upon by the sending and receiving parties.

Answer: C

NEW QUESTION 8
To see that utilization guidelines are consistently applied, UR programs rely on authorization systems. Determine whether the following statement about authorization systems is true or false:
Only physicians can make nonauthorization decisions based on medical necessity.

  • A. True
  • B. False

Answer: A

NEW QUESTION 9
Health plans often use accreditation as a means of evaluating the quality of care delivered to plan members. Accreditation of subacute care providers is available from the

  • A. National Committee for Quality Assurance (NCQA)
  • B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
  • C. American Accreditation HealthCare Commission/URAC (URAC)
  • D. Foundation for Accountability (FACCT)

Answer: B

NEW QUESTION 10
By definition, the development and implementation of parameters for the delivery of healthcare services to a health plan’s members is known as

  • A. utilization management (UM)
  • B. quality management (QM)
  • C. care management
  • D. clinical practice management

Answer: D

NEW QUESTION 11
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 12
The following statements are about medical management considerations for dental care. Select the answer choice containing the correct statement.

  • A. Managed dental care organizations are regulated at the state rather than the federal level.
  • B. Dental care differs from medical care in that most dental care is provided by specialists.
  • C. Dental preferred provider organizations (Dental PPOs) are subject to more regulation than are dental health maintenance organizations (DHMOs).
  • D. Managed dental plans are accredited by the National Association of Dental Plans (NADP).

Answer: A

NEW QUESTION 13
Three general categories of coverage policy—medical policy, benefits administration policy, and administrative policy—are used in conjunction with purchaser contracts to determine a health plan’s coverage of healthcare services and supplies. With respect to the characteristics of the three types of coverage policy, it is correct to say that a health plan’s

  • A. medical policy evaluates clinical services against specific benefits language rather than against scientific evidence
  • B. benefits administration policy determines whether a particular service is experimental or investigational
  • C. benefits administration policy focuses on both clinical and nonclinical coverage issues
  • D. administrative policy contains the guidelines to be followed when handling member and provider complaints and disputes

Answer: D

NEW QUESTION 14
To facilitate electronic commerce (eCommerce), a health plan may establish a secured extranet. One true statement about a secured extranet is that it is

  • A. based on Web-based technologies
  • B. available only to the employees of the health plan
  • C. publicly available, so the potential exists for unauthorized access to a health plan’s proprietary systems
  • D. used to handle the majority of health plan eCommerce

Answer: A

NEW QUESTION 15
One way that health plans evaluate their UR programs is by monitoring utilization rates. By definition, utilization rates typically

  • A. indicate changes in the total amount of medical expenses or claim dollars paid for particular procedures
  • B. measure the number of services provided per 1,000 members per year
  • C. indicate standard approaches to care for many common, uncomplicated healthcare services
  • D. report the number of times that a particular provider performs or recommends a service excluded from the benefit plan

Answer: B

NEW QUESTION 16
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