Weekend Sale - Special 70% Discount Offer - Ends in 0d 00h 00m 00s - Coupon code: 70dumps

AHM-250 Questions and Answers

Question # 6

The process that Mr. Sybex used to identify and classify the risk represented by the Koster Group so that Intuitive can charge premiums that are adequate to cover its expected costs is known as

A.

coinsurance

B.

plan funding

C.

underwriting

D.

pooling

Full Access
Question # 7

The following statements describe common types of physician/hospital integrated models:

The Iota Company, which is owned by a group of investors, is a for-profit legal entity that buys entire physician practices, not just the tangible assets of the practice

A.

Iota- physician hospital organization (PHO)Casa- physician practice management (PPM) company.

B.

Iota- physician hospital organization (PHO)Casa- medical foundation.

C.

Iota- physician practice management (PPM) Casa- physician hospital organization (PHO) company.

D.

Iota- medical foundation Casa- management services organization (MSO).

Full Access
Question # 8

An HMO’s quality assurance program must include

A.

A statement of the HMO’s goals and objectives for evaluating and improving enrollees’ health status

B.

Documentation of all quality assurance activities

C.

System for periodically reporting program results to the HMO’s board of directors, its providers, and regulators

D.

All the above

Full Access
Question # 9

System classifies hundreds of hospital services based on a number of criteria, such as primary and secondary diagnosis, surgical procedures, age, gender, and the presence of complications.

A.

Carve-out

B.

DRG

C.

Global capitation

D.

Partial capitation

Full Access
Question # 10

Specialty services that have certain characteristics generally are good candidates for managed care approaches. These characteristics generally include that the specialty service should have

A.

appropriate, rather than inappropriate, utilization

B.

a defined patient population

C.

low, stable costs

D.

a benefit that cannot be easily defined

Full Access
Question # 11

Many of the credentialing standards and criteria used by health plans are often taken from already existing standards established by

A.

the National Practitioner Data Bank (NPDB)

B.

the National Association of Insurance Commissioners (NAIC)

C.

the Centers for Medicare and Medicaid Services (CMS)

D.

independent accrediting organizations

Full Access
Question # 12

Khalyn Drury's employer includes managed dental care in its employee benefits package. During open enrollment, Ms. Drury enrolled in the dental plan, which provides dental services to its members in exchange for a prepayment (the premium). Dental services

A.

dental preferred provider organization (PPO)

B.

traditional fee-for-service (FFS) dental plan

C.

plan with a dental point of service (POS) option

D.

dental health maintenance organization (DHMO)

Full Access
Question # 13

Parable Healthcare Providers, a health plan, recently segmented the market for a new healthcare service. Parable began the process by dividing the healthcare market into two broad categories: non-group and group. Next, Parable further segmented the non-gr

A.

channel segmentation

B.

geographic segmentation

C.

demographic segmentation

D.

product segmentation

Full Access
Question # 14

Individuals can use HSAs to pay for the following types of health coverage:.

A.

Qualified disability insurance

B.

COBRA continuation coverage.

C.

Medigap coverage (for those over 65).

D.

All of the above.

Full Access
Question # 15

Parul Gupta has been covered by a group health plan for eighteen months. For the past four months, she has been undergoing treatment for diabetes. Last week, Ms. Gupta began a new job and immediately enrolled in her new company's group health plan, which

A.

can exclude coverage for treatment of Ms. Gupta's diabetes for one year, because she did not have at least two years of creditable coverage under her previous health plan

B.

cannot exclude Ms. Gupta's diabetes as a pre-existing condition, because the one-year pre-existing condition provision is offset by at least one year of continuous coverage under her previous health plan

C.

can exclude coverage for treatment of Ms. Gupta's diabetes for one year, because HIPAA does not impact a group health plan's pre-existing condition provision

D.

can exclude coverage for treatment of Ms. Gupta's diabetes for four months, because that is the length of time she received treatment for this medical condition prior to her enrollment in the new health plan

Full Access
Question # 16

Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the

A.

Hill had to have an initial net worth of at least $1.5 million in order to obtain a COA.

B.

The COA most likely exempts Hill from any of State X's enabling statutes.

C.

Hill had to be organized as a partnership in order to obtain a COA

D.

The COA in no way indicates that Hill has demonstrated that it is fiscally sound.

Full Access
Question # 17

In 1999, the United States Congress passed the Financial Services Modernization Act, which is referred to as the Gramm-Leach-Bliley (GLB) Act. The following statement(s) can correctly be made about this act:

A.

The GLB Act allows convergence among the transaction

B.

A only

C.

Both A and B

D.

B only

E.

Neither A nor B

Full Access
Question # 18

HMOs typically employ several techniques to manage provider utilization and member utilization of medical services. One technique that an HMO uses to manage member utilization is

A.

the use of physician practice guidelines

B.

the requirement of copayments for office visits

C.

capitation

D.

risk pools

Full Access
Question # 19

Federal Employee Health Benefits Program (FEHBP) requires health plans offering services to federal employees and their dependents to provide

A.

Immediate access to emergency services

B.

Urgent Appointments within 24 hours

C.

Routine appointments once a m

D.

D

E.

A

F.

B & C

G.

All of the listed options

Full Access
Question # 20

A particular health plan offers a higher level of benefits for services provided in-network than for out-of-network services. This health plan requires preauthorization for certain medical services.

With regard to the steps that the health plan's claims e

A.

should assume that all services requiring preauthorization have been preauthorized

B.

should investigate any conflicts between diagnostic codes and treatment codes before approving the claim to ensure that the appropriate payment is made for the claim

C.

need not verify that the provider is part of the health plan's network before approving the claim at the in-network level of benefits

D.

need not determine whether the member is covered by another health plan that allows for coordination of benefits

Full Access
Question # 21

Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. Specialty services that have certain characteristics are generally good candidates for health pl

A.

Low or stable costs.

B.

Appropriate, rather than inappropriate, utilization rates.

C.

A benefit that cannot be easily defined.

D.

Defined patient population.

Full Access
Question # 22

Merle Spencer has coverage under both Medicare Part A and Medicare Part B. Ms. Spencer recently was hospitalized for chest pains, and she incurred charges for:

  • The cost of hospitalization for two days
  • Diagnostic tests performed in the hospital
  • Trans

A.

ambulance and the diagnostic tests

B.

ambulance, the diagnostic tests, and the physician's professional services

C.

cost of hospitalization

D.

cost of hospitalization and the physician's professional services

Full Access
Question # 23

The following statements are about the various Health Plan Accountability Models adopted by the NAIC.

A.

Under the terms of the Health Plan Network Adequacy Model Act, all health plans would be required to hold covered persons harmless against provider collections and provide continued coverage for uncompleted treatment in the event of plan insolvency

B.

The Health Carrier Grievance Procedure Model Act requires all health carriers to maintain a first-level grievance review, but it does not require any second-level review

C.

According to the Health Care Professional Credentialing Verification Model Act, a health plan must select all providers who meet the plan's credentialing criteria

D.

The Quality Assessment and Improvement Model Act exempts closed plans from implementing a quality improvement program.

Full Access
Question # 24

Natalie Chan is a member of the Ultra Health Plan. Whenever she needs non-emergency medical care, she sees Dr. David Craig, an internist. Ms. Chan cannot self-refer to a specialist, so she saw Dr. Craig when she experienced headaches. Dr. Craig referred h

A.

Within Ultra's system, Ms. Chan received primary care from both Dr. Craig and Dr. Lee.

B.

Ultra's system allows its members open access to all of Ultra's participating providers.

C.

Within Ultra's system, Dr. Craig serves as a coordinator of care or gatekeeper for the medical services that Ms. Chan receives.

D.

Ultra's network of providers includes Dr. Craig and Dr. Lee but not Arrow Hospital.

Full Access
Question # 25

One of the distinguishing characteristics of healthcare marketing is that many of the markets for health plans are national, not local markets.

A.

True

B.

False

Full Access
Question # 26

One type of physician-only integration model is a consolidated medical group. Typical characteristics of a consolidated medical group include

A.

that it may be a single-specialty or multi-specialty practice

B.

operates in one or a few facilities rather than in many independent offices

C.

achieves economies of scale in the group's integrated operations

D.

all of the above

Full Access
Question # 27

The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to be

A.

Credentialing

B.

Accreditation

C.

A sentinel event

D.

A screening program

Full Access
Question # 28

The Cleopatra Group, a third-party administrator (TPA), has entered into a TPA agreement with the Alexander MCO with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. On

A.

hold all funds it receives on behalf of Alexander in trust

B.

assume full responsibility for determining the claim payment procedures for the plan

C.

assume full responsibility for ensuring that the health plan is administered properly

D.

obtain from the federal government a certificate of authority designating the Cleopatra Group as a TPA

Full Access
Question # 29

Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involves

A.

ascertaining that physicians in the plan have the necessary and appropriate credentials to prescribe medications

B.

compiling data on physician prescribing patterns and comparing physicians' actual prescribing patterns to expected patterns within select drug categories

C.

monitoring patient-specific drug problems through concurrent and retrospective review

D.

establishing protocols that require physicians to obtain certification of medical necessity prior to drug dispensing

Full Access
Question # 30

One ethical principle in managed care is the principle of justice/equity, which specifically holds that MCOs and their providers have a duty to

A.

treat each member in a manner that respects his or her own goals and values

B.

allocate resources in a way that fairly distributes benefits and burdens among the members

C.

present information honestly to their members and to honor commitments to their members

D.

make sure they do not harm their members

Full Access
Question # 31

The Blaine Healthcare Corporation seeks to manage its quality by first identifying the best practices and best outcomes for a given procedure. Blaine can then determine areas in which it can emulate the best practices in order to equal or surpass the best

A.

provider profiling

B.

benchmarking

C.

peer review

D.

quality assessment

Full Access
Question # 32

Janet Riva is covered by a indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan. She incurred

A.

$1,750

B.

$1,800

C.

$2,000

D.

$2,250

Full Access
Question # 33

The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential

A.

An indemnity wraparound plan

B.

A self-funded plan

C.

An aggregate stop-loss plan

D.

A fully funded plan

Full Access
Question # 34

Which of the following is WRONG?

A.

Computer Based Patient Records Institute (CPRI) developed the standards for digital imaging of xrays.

B.

HL7 developers focuses on interchange of Clinical Health Data

C.

ANSI, a voluntary national standards organization, creates a consensus based process by which fair and equitable standards can be developed and serves as a legitmizer of standards.

D.

American Health Information Management Association focuses on EDI standards for exchange of clinical data

Full Access
Question # 35

When the Knoll Company purchased group health coverage from the Castle Health Maintenance Organization (HMO), the agreement between the two parties specified that the plan would be a typical fully funded plan. Because Knoll had been covered under a previo

A.

Castle is responsible for paying for all incurred covered benefits

B.

Knoll is solely responsible for guaranteeing claim payments

C.

Knoll makes no premium payments to Castle

D.

Castle has no responsibilities for administering the health plan

Full Access
Question # 36

Which facility would best meet the need of Jack who fell on road and sprained his ankle?

A.

Emergency Department

B.

Urgent Care Centre

C.

Home health care

D.

None of the above

Full Access
Question # 37

The nature of the claims function within health plans varies by type of plan and by the compensation arrangement that the plan has made with its providers. For example, it is generally correct to say that, in a

A.

Preferred provider organization (PPO), the

B.

Both A and B

C.

A only

D.

B only

E.

Neither A nor B

Full Access
Question # 38

Consolidation of patient information in a single location as can be used by independent providers is an example of

A.

Structural Integration

B.

Operational Integration

C.

Business Integration

D.

None of the above

Full Access
Question # 39

The measures used to evaluate healthcare quality are generally divided into three categories: process, structure, and outcomes. An example of a process measure that can be used to evaluate a health plan's performance is the:

A.

Percentage of adult plan members who receive regular medical checkups.

B.

Number of plan members contracting an infection in the hospital.

C.

Percentage of board certified physicians within the health plan's network.

D.

Number of hospital admissions for plan members with certain medical conditions.

Full Access
Question # 40

The process of identifying and classifying the risk represented by an individual or group is called

A.

Rating

B.

Anti selection

C.

Underwriting

D.

None of the above

Full Access
Question # 41

The statements below describe technology used by two health plans to respond to incoming telephone calls:

  • The Manor Health Plan uses an automated system that answers telephone calls with recorded or synthesized speech and prompts the caller to respond t

A.

Manor's system is best described as an automated call distributor (ACD).

B.

Both Manor's system and Squire's device are applications of computer/telephone integration (CTI).

C.

Squire's device is best described as an interactive voice response (IVR) system.

D.

All of these statements are correct.

Full Access
Question # 42

Which of the following statements is FALSE?

A.

The license that HMOs get in each state is called ‘Certificate of Authority’

B.

The HMO contracts directly with the individual physicians who provide the medical services to the HMO members in a variation of the IPA model called direct contract model HMO.

C.

All medicare/mediclaim beneficiaries should comply with utilization management requirements set forth by HCFA

D.

HMO’s usually impose high coinsurance or deductible requirements

Full Access
Question # 43

In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known

A.

dual choice

B.

cost shifting

C.

accreditation

D.

defensive medicine

Full Access
Question # 44

During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, fo

A.

the angina, the high blood pressure, and the broken ankle

B.

the angina and the high blood pressure only

C.

none of these conditions

D.

the broken ankle only

Full Access
Question # 45

In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of

A.

Prospective review

B.

Concurrent review

C.

D.

A, B, and C

E.

A and B only

F.

A and C only

G.

B only

Full Access
Question # 46

Health savings accounts were created by which of the following laws:

A.

COBRA

B.

HIPAA

C.

Medicare Modernization Act

D.

None of the Above

Full Access
Question # 47

For providers, integration occurs when two or more previously separate providers combine under common ownership or control, or when two or more providers combine business operations that they previously carried out separately and independently. Such provi

A.

higher costs for health plans, healthcare purchasers, and healthcare consumers

B.

improved provider contracting position with health plans

C.

an increase in providers' autonomy and control over their own work environment

D.

all of the above

Full Access
Question # 48

In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of

A.

Prospective review

B.

Concurrent review

C.

D.

A, B, and C

E.

A and B only

F.

A and C only

G.

B only

Full Access
Question # 49

In order to cover some of the gap between FFS Medicare coverage and the actual cost of services, beneficiaries often rely on Medicare supplements. Which of the following statements about Medicare supplements is correct?

A.

The initial ten (A-J) Medigap policies offer a basic benefit package that includes coverage for Medicare Part A and Medicare Part B coinsurance.

B.

Each insurance company selling Medigap must sell all the different Medigap policies.

C.

Medicare SELECT is a Medicare supplement that uses a preferred provider organization (PPO) to supplement Medicare Part A coverage.

D.

Medigap benefits vary by plan type (A through L), and are not uniform nationally.

Full Access
Question # 50

Using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider is called ______________.

A.

Coding error

B.

Overcharging

C.

Upcoming

D.

Unbundling

Full Access
Question # 51

If left unresolved, member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info

A.

A Level One appeal, and the member has the right to a further appeal

B.

A Level Two appeal, and the reviewer's decision is final and binding

C.

An independent external appeal, and the member has the right to a further appeal

D.

Arbitration, and the reviewer's decision is final and binding

Full Access
Question # 52

As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members:

  • Brad Van Note, age 28, is taking many different, costly medications for

A.

Mr. Van Note, Mr. Albrecht, and Ms. Cromartie

B.

Mr. Van Note and Ms. Cromartie only

C.

Mr. Van Note and Mr. Albrecht only

D.

Mr. Albrecht and Ms. Cromartie only

Full Access
Question # 53

Greentree Medical, a health plan, is currently recruiting PCPs in preparation for its expansion into a new service area. Abigail Davis, a recruiter for Greentree, has been meeting with Melissa Cortelyou, M.D., in an effort to recruit her as a PCP in Green

A.

Greentree is prevented by law from offering a contract to Dr. Cortelyou until the credentialing process is complete

B.

any contract signed by Dr. Cortelyou should include a clause requiring the successful completion of the credentialing process within a defined time frame in order for the contract to be effective

C.

Greentree must offer a standard contract to Dr. Cortelyou, without regard to the outcome of the credentialing process

D.

Greentree will abandon the credentialing process now that Dr. Cortelyou has agreed to participate in Greentree's network

Full Access
Question # 54

In assessing the potential degree of risk represented by a proposed insured, a health underwriter considers the factor of anti selection. Anti selection can correctly be defined as the

A.

inability of a proposed insured to share with the insurer the financial risks of healthcare coverage

B.

possibility that a proposed insured will profit from an illness by receiving benefits that exceed the total amount of his or her eligible medical expenses

C.

inability of a proposed insured to provide sufficient evidence that proves he or she is an insurable risk

D.

tendency of people who have a greater-than-average likelihood of loss to apply for or continue insurance protection to a greater extent than people who have an average or less than average likelihood of the same loss

Full Access
Question # 55

A health savings account must be coupled with an HDHP that meets federal requirements for minimum deductible and maximum out-of-pocket expenses. Dollar amounts are indexed annually for inflation. For 2006, the annual deductible for self-only coverage must

A.

$525

B.

$1,050

C.

$2,100

D.

$5,250

Full Access