The Secret Of AHIP AHM-530 Prep

NEW QUESTION 1

Reimbursement for prescription drugs and services in a third-party prescription drug plan typically follows one of two approaches: a reimbursement approach or a service approach. One true statement about these approaches is that:

• A. Payments under the reimbursement method typically are not subject to any copayment or deductible requirements
• B. Payments under the reimbursement approach are typically based on a structured reimbursement schedule rather than on usual, customary, and reasonable (UCR) charges
• C. Most major medical plans follow a service approach
• D. Most current health plan prescription drug plans are service plans

Answer: D

NEW QUESTION 2

The provider contract that Dr. Lorena Chau has with the Fiesta Health Plan includes an evergreen clause. The purpose of this clause is to:

• A. Allow Fiesta to change or amend the contract without D
• B. Chau's approval as long as the modifications are made in order to comply with new legal and regulatory requirements
• C. Prohibit D
• D. Chau from encouraging her patients to switch from Fiesta to another health plan
• E. Prohibit D
• F. Chau from encouraging her patients to switch from Fiesta to another health plan
• G. Assure that D
• H. Chau provides Fiesta members with healthcare services in a timely manner appropriate to the member's medical condition

Answer: C

NEW QUESTION 3

Dr. Sylvia Cimer and Dr. Andrew Donne are obstetrician/gynecologists who participate in
the same provider network. Dr. Comer treats a large number of high-risk patients, whereas Dr. Donne’s patients are generally healthy and rarely present complications. As a result, Dr. Comer typically uses medical resources at a much higher rate than does Dr. Donne. In order to equitably compare Dr. Comer’s performance with Dr. Donne’s performance, the health plan modified its evaluation to account for differences in the providers’ patient populations and treatment protocols. The health plan modified Dr. Comer’s and Dr. Donne’s performance data by means of

• A. Acase mix/severity adjustment
• B. An external performance standard
• C. Structural measures
• D. Behavior modification

Answer: A

NEW QUESTION 4

The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
The comparative method of evaluation that Azure uses to identify and implement the practices that lead to the best outcomes is known as

• A. Case mix analysis
• B. Outcomes research
• C. Benchmarking
• D. Provider profiling

Answer: C

NEW QUESTION 5

The following statements are about factors that health plans should consider as they develop provider networks in rural and urban markets. Three of the statements are true, and one of the statements is false. Select the answer choice that contains the FALSE statement.

• A. Compared to providers in urban areas, providers in rural areas are less likely to offer discounts to health plans in exchange for directed patient volume.
• B. In urban areas, limiting the number of specialists on a panel usually affects the network’s market appeal more than does limiting the number of primary care physicians.
• C. The greatest opportunity to create competition in rural areas is among the specialty providers in other nearby communities.
• D. Typically, hospital contracting is easier in urban areas than in rural areas.

Answer: B

NEW QUESTION 6

If a third party is responsible for injuries to a plan member of the Hope Health Plan, then Hope has a contractual right to file a claim for the resulting healthcare costs against the third party. This contractual right to recovery from the third party is known as

• A. Subrogation
• B. Partial capitation
• C. Coordination of benefits
• D. Aremedy provision

Answer: A

NEW QUESTION 7

The Pine Health Plan has incorporated pharmacy benefits management into its operations to form a unified benefit. Potential advantages that Pine can receive from this action include:

• A. the fact that unified benefits improve the quality of patient care and the value of pharmacy services to Pine's plan members
• B. the fact that control over the formulary and network contracting can give Pine control over patient access to prescription drugs and to pharmacies
• C. the fact that managing pharmacy benefits in-house gives Pine a better chance to meet customer needs by integrating pharmacy services into the plan's total benefits package
• D. all of the above

Answer: D

NEW QUESTION 8

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.
The following statement(s) can correctly be made about Gardenia’s establishment of the PPO and the staff model HMO in its new market:
* 1. When establishing its PPO network, Gardenia most likely initiated outcomes measurement tools and developed collaborative process improvement relationships with providers.
* 2. To avoid high overhead expenses in the early stages of market evelopment, Gardenia’s HMO most likely contracted with specialists and ancillary providers until the plan’s membership grew to a sufficient level to justify employing these specialists.

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

Answer: D

NEW QUESTION 9

The Omnibus Budget Reconciliation Act of 1986 (OBRA 1986) established the Programs of All-Inclusive Care for the Elderly (PACE). One characteristic of the PACE programs is that:

• A. They are available to United States citizens only after they reach age 65.
• B. They have an upper dollar limit.
• C. They receive a monthly capitation that is set at 100% of the Adjusted Average Per Capita Cost (AAPCC).
• D. PACE providers receive capitated payments only through the PACE agreement.

Answer: D

NEW QUESTION 10

When evaluating the success of providers in meeting standards, a health plan must make adjustments for case mix or severity. One true statement about case mix/severity adjustments is that they:

• A. Typically are more important in measuring the performance of PCPs than they are in measuring the performance of specialists
• B. Help compensate for any unusual factors that may exist in a provider's patient population or in a particular patient
• C. Tend to increase the number of providers who are considered to be outliers
• D. Allow for a more equitable comparison of data between providers of outpatient care but not providers of inpatient care

Answer: B

NEW QUESTION 11

In health plan pharmacy networks, service costs consist of two components: costs for services associated with dispensing prescription drugs and costs for cognitive services. Cognitive services typically include:

• A. making generic substitutions of drugs
• B. counseling patients about prescriptions
• C. providing patient monitoring
• D. switching prescription drugs to preferred drugs

Answer: B

NEW QUESTION 12

The Octagon Health Plan includes a typical indemnification clause in its provider contracts. The purpose of this clause is to require Octagon’s network providers to

• A. Agree not to sue or file claims against an Octagon plan member for covered services
• B. Reimburse Octagon for costs, expenses, and liabilities incurred by the health plan as a result of a provider’s actions
• C. Maintain the confidentiality of the health plan’s proprietary information
• D. Agree to accept Octagon’s payment as payment in full and not to bill members for anything other than contracted copayments, coinsurance, or deductibles

Answer: B

NEW QUESTION 13

The following statements describe two types of HMOs:
The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.
The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.
Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the NewnanGroup, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.
Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:
The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents per tablet for this drug.
The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.
The following statements can correctly be made about the reimbursement for Drugs A and B under the MAC pricing system:

• A. Treble most likely is obligated to reimburse Manor 14 cents per tablet for Drug A.
• B. Manor most likely is allowed to bill the subscriber 2 cents per tablet for Drug A.
• C. Treble most likely is obligated to reimburse Manor 5 cents per tablet for Drug B.
• D. All of the above statements are correct.

Answer: C

NEW QUESTION 14

Grant Pelham is covered by both a workers’ compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.
Mr. Pelham’s group health insurance plan and workers’ compensation both provide benefits to cover expenses incurred as a result of illness or injury. However, unlike traditional group insurance coverage, workers’ compensation

• A. Provides reimbursement for lost wages
• B. Requires employees who suffer a work-related illness or injury to obtain care from specified network providers
• C. Covers all injuries and illnesses, regardless of their cause
• D. Requires employees to share the cost of treatment through deductible, coinsurance, and benefit limits

Answer: A

NEW QUESTION 15

The provider contract that Dr. Huang Kwan has with the Poplar Health Plan includes a typical scope of services provision. The medical service that Dr. Kwan provided to Alice Meyer, a Poplar plan member, is included in the scope of services. The following statement(s) can correctly be made about this particular medical service:

• A. D
• B. Kwan most likely was required to seek authorization from Poplar before performing this particular service.
• C. D
• D. Kwan most likely was paid on a FFS basis for providing this service.
• E. Both A and B
• F. A only
• G. B only
• H. Neither A nor B

Answer: D

NEW QUESTION 16

Dr. Ahmad Shah and Dr. Shantelle Owen provide primary care services to Medicare+Choice enrollees of health plans under the following physician incentive plans:
Dr. Shah receives $40 per enrollee per month for providing primary care and an additional
$10 per enrollee per month if the cost of referral services falls below a specified level
Dr. Owen receives $30 per enrollee per month for providing primary care and an additional
$15 per enrollee per month if the cost of referral services falls below a specified level The use of a physician incentive plan creates substantial risk for

• A. Both D
• B. Shah and D
• C. Owen
• D. D
• E. Shah only
• F. D
• G. Owen only
• H. Neither D
• I. Shah nor D
• J. Owen

Answer: C

NEW QUESTION 17

The Tuba Health Plan recently underwent an accreditation process under a program known as Accreditation '99, which includes selected Health Employer Data and Information Set (HEDIS) measures. Under Accreditation '99, Tuba received a rating of Excellent. The following statement(s) can correctly be made about this quality assessment of Tuba's operations:

• A. In arriving at its rating of Excellent for Tuba, the Accreditation '99 program most likely focused on Tuba's demonstrated results and evaluated the processes that Tuba used to achieve those results.
• B. Tuba is required to report all HEDIS results to the NAIC.
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: B

NEW QUESTION 18
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