The Regenerate Guide To AHM-530 Real Exam

NEW QUESTION 1

The following statements are about managed dental care. Three of these statements are true, and one is false. Select the answer choice containing the FALSE statement.

• A. Managed dental care is federally regulated.
• B. Dental HMOs typically need very few healthcare facilities because almost all dental services are delivered in an ambulatory care setting.
• C. Currently, there are no nationally recognized standards for quality in managed dental care.
• D. Processes for selecting dental care providers vary greatly according to state regulationson managed dental care networks and the health plan’s standards.

Answer: A

NEW QUESTION 2

For this question, if answer choices (A) through C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Understanding the level of health plan penetration in a particular market can help a health plan determine which products are most appropriate for that market. Indicators of a mature health plan market include

• A. Areduction in the rate of growth in health plan premium levels
• B. Areduction in the level of outcomes management and improvement
• C. An increase in the rate of inpatient hospital utilization
• D. All of the above

Answer: A

NEW QUESTION 3

Salvatore Arris is a member of the Crescent Health Plan, which provides its members with a full range of medical services through its provider network. After suffering from debilitating headaches for several days, Mr. Arris made an appointment to see Neal Prater, a physician’s assistant in the Crescent network who provides primary care under the supervision of physician Dr. Anne Hunt. Mr. Prater referred Mr. Arris to Dr. Ginger Chen, an ophthalmologist, who determined that Mr. Arris’ symptoms were indicative of migraine headaches. Dr. Chen prescribed medicine for Mr. Arris, and Mr. Arris had the prescription filled at a pharmacy with which Crescent has contracted. The pharmacist, Steven Tucker, advised Mr. Arris to take the medicine with food or milk. In this situation, the person who functioned as an ancillary service provider is

• A. M
• B. Prater
• C. D
• D. Hunt
• E. D
• F. Chen
• G. M
• H. Tucker

Answer: D

NEW QUESTION 4

The BBA of 1997 specifies the ways in which a Medicare+Choice plan can establish and use provider networks. A Medicare+Choice plan that operates as a private fee for service (PFFS) plan is allowed to

• A. limit the size of its network to the number of providers necessary to meet the needs of its enrollees
• B. require providers to accept as payment in full an amount no greater than 115% of the Medicare payment rate
• C. refuse payment to non-network providers who submit claims for Medicare-coveredexpenses
• D. shift all risk for Medicare-covered services to network providers

Answer: B

NEW QUESTION 5

Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be

• A. $42,857
• B. $56,700
• C. $272,160
• D. $680,400

Answer: C

NEW QUESTION 6

The provider contracts that the Indigo Health Plan has with its providers include a clause which states that Indigo's denial of payment for a certain medical procedure does not constitute a medical opinion and is not intended to interfere with the provider-patient relationship. This information indicates that Indigo's provider contracts include:

• A. A business confidentiality clause.
• B. A scope of services clause.
• C. An informed refusal clause.
• D. An exculpation clause.

Answer: D

NEW QUESTION 7

The following statement(s) can correctly be made about hospitalists.
* 1. The hospitalist’s main function is to coordinate diagnostic and treatment activities to ensure that the patient receives appropriate care while in the hospital.
* 2. The hospitalist’s role clearly supports the health plan concept of disease management.

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

Answer: B

NEW QUESTION 8

The vision benefits offered by the Omni Health Plan include clinical eye care only. The following statements describe vision care received by Omni plan members:
•Brian Pollard received treatment for a torn retina he suffered as a result of an accident
•Angelica Herrera received a general eye examination to test her vision
•Megan Holtz received medical services for glaucoma
Of these medical services, the ones that most likely would be covered by Omni's vision coverage would be the services received by:

• A. M
• B. Pollard, M
• C. Herrera, and M
• D. Holtz
• E. M
• F. Pollard and M
• G. Herrera only
• H. M
• I. Pollard and M
• J. Holtz only
• K. M
• L. Herrera and M
• M. Holtz only

Answer: C

NEW QUESTION 9

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 10

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 11

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 12

As part of the credentialing process, many health plans use the National Practitioner Data Bank (NPDB) to learn information about prospective members of a provider network. One true statement about the NPDB is that:

• A. It is maintained by the individual states
• B. It primarily includes information about any censures, reprimands, or admonishments against any physicians who are licensed to practice medicine in the United States
• C. The information in the NPDB is available to the general public
• D. It was established to identify and discipline medical practitioners who act unprofessionally

Answer: D

NEW QUESTION 13

The provider contract that Dr. Bijay Patel has with the Arbor Health Plan includes a no- balance-billing clause. The purpose of this clause is to:

• A. prohibit D
• B. Patel from collecting payments from Arbor plan members for medical services that he provided them, even if the services are explicitly excluded from the benefit plan
• C. allow D
• D. Patel to bill patients for services only if the services are considered to be medically necessary
• E. establish the guidelines used to determine if Arbor is the primary payor of benefits in a situation in which an Arbor plan member is covered by more than one health plan
• F. require D
• G. Patel to accept Arbor's payment as payment in full for medical services that he provides to Arbor plan members

Answer: D

NEW QUESTION 14

Assume that the national average cost per covered employee for PPO rental networks is
$3 per member per month (PMPM) and that the average monthly healthcare premium PMPM is $300. This information indicates that, if the number of health plan members is 10,000, then the annual network rental cost to the health plan would be:

• A. $30,000
• B. $360,000
• C. $9,000,000
• D. $12,000,000

Answer: B

NEW QUESTION 15

Medicaid is a joint federal and state program that provides healthcare coverage for low- income, medically needy, and disabled individuals. Under the terms of this joint sponsorship, the

• A. Federal government is responsible for making all claim payments
• B. Federal government is responsible for determining the basic benefits that must be provided to eligible Medicaid beneficiaries
• C. State governments are responsible for setting minimum standards regarding eligibility, benefit coverage, and provider participation and reimbursement
• D. State governments are responsible for establishing overall regulation of the Medicaid program

Answer: B

NEW QUESTION 16

The Ross Health Plan compensates Dr. Cecile Sanderson on a FFS basis. In order to increase the level of reimbursement that she would receive from Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The services she actually provided represented an intermediate level of service. Dr. Sanderson’s action is an example of a type of false billing procedure known as

• A. Cost shifting
• B. Churning
• C. Unbundling
• D. Upcoding

Answer: D

NEW QUESTION 17

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. A credentials verification organization (CVO) can be certified to verify certain pertinent credentialing information, including

• A. Liability claims histories of prospective providers
• B. Hospital privileges of prospective providers
• C. Malpractice insurance on prospective providers
• D. All of the above

Answer: D

NEW QUESTION 18
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