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Ace the AHIP AHM-250 Exam: Ultimate Preparation Guide

Questions 101

Provider integration has two components: operational integration and structural integration. An example of operational integration in health plans is the:

Options:

A.

Acquisition of the Leopard Health Plan by the Hickory Health Plan.

B.

Joint venture entered into by the Eclipse Health Plan and a local hospital system to create a new health plan in which Eclipse and the hospital system share ownership.

C.

Formation of an organization by a group of providers to carry out billing, collections, and contracting with health plans for the entire group of providers.

D.

Consolidation of the Carver Health Plan and the Limestone Health Plan.

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Questions 102

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

Options:

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

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Questions 103

The application of health plan principles to workers' compensation insurance programs has presented some unique challenges because of the differences between health plan for traditional group healthcare and workers' compensation. One key difference is that

Options:

A.

limits coverage to eligible employees and excludes part-time employees

B.

specifies an annual lifetime benefit maximum on dollar coverage for medical costs

C.

provides benefits regardless of the cause of an injury or illness

D.

provides benefits for both healthcare costs and lost wages

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Questions 104

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

Options:

A.

provider profiling

B.

benchmarking

C.

peer review

D.

quality assessment

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Questions 105

One way in which health plans differ from traditional indemnity plans is that health plans typically

Options:

A.

provide less extensive benefits than those provided under traditional indemnity plans

B.

place a greater emphasis on preventive care than do traditional indemnity plans

C.

require members to pay a percentage of the cost of medical services rendered after a claim is filed, rather than a fixed copayment at the time of service as required by indemnity plans

D.

contain cost-sharing requirements that result in more out-of-pocket spending by members than do the cost-sharing requirements in traditional indemnity plans

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Questions 106

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

Options:

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

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Questions 107

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

Options:

A.

Credentialing

B.

Accreditation

C.

A sentinel event

D.

A screening program

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Questions 108

Specialty services with certain characteristics tend to make good candidates for health plan approaches. One characteristic used to identify a specialty service that may be a good candidate for a health plan approach is that the service should have

Options:

A.

a defined patient population

B.

a complex benefit structure

C.

low, stable costs

D.

appropriate utilization rates

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Questions 109

Paul Gilbert has been covered by a group health plan for two years. He has been undergoing treatment for angina for the past three months. Last week, Mr. Gilbert began a new job and immediately enrolled in his new company's group health plan, which has a

Options:

A.

Can exclude coverage for treatment of Mr. Gilbert's angina for one year, because HIPAA does not impact a group health plan's pre-existing condition provision.

B.

Can exclude coverage for treatment of Mr. Gilbert's angina for one year, because Mr. Gilbert did not have at least 36 months of creditable coverage under his previous health plan.

C.

Can exclude coverage for treatment of Mr. Gilbert's angina for three months, because that is the length of time he received treatment for this medical condition prior to his enrollment in the new health plan.

D.

Cannot exclude his angina as a pre-existing condition, because the one-year pre-existing condition provision is offset by at least one year of continuous coverage under his previous health plan.

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Questions 110

Managed behavioral health organizations (MBHOs) use several strategies to manage the delivery of behavioral healthcare services. The following statements are about these strategies.

Select the answer choice that contains the correct statement.

Options:

A.

MBHOs generally provide benefits for mental health services but not for chemical dependency services.

B.

The level of care needed to treat behavioral disorders is the same for all patients and all disorders.

C.

By using outpatient treatment more extensively, MBHOs have decreased the use of costly inpatient therapies.

D.

PCP gatekeeper systems for behavioral healthcare generally result in more accurate diagnoses, more effective treatment, and more efficient use of resources than do centralized referral systems.

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