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Ace the AHIP AHM-250 Exam: Ultimate Preparation Guide

Questions 11

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

Options:

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

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Questions 12

One non-group market segment to which health plans market health plan products is the senior market, which is comprised mostly of persons over age 65 who are eligible for Medicare benefits. One factor that affects a health plan's efforts to market to the

Options:

A.

The Centers for Medicare and Medicaid Services (CMS) must approve all marketing materials used by health plans to market health plan products to the Medicare population

B.

managed Medicare plans typically require Medicare beneficiaries to purchase Medigap insurance to supplement gaps in coverage

C.

managed Medicare plans can refuse to cover persons with certain health problems

D.

the CMS prohibits health plans from using telemarketing to market health plan products to the Medicare population

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Questions 13

One typical characteristic of an integrated delivery system (IDS) is that an IDS.

Options:

A.

Is more highly integrated structurally than it is operationally.

B.

Provides a full range of healthcare services, including physician services, hospital services, and ancillary services.

C.

Cannot negotiate directly with health plans, plan sponsors, or other healthcare purchasers.

D.

Performs a single business function, such as negotiating with health plans on behalf of all of the member providers.

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Questions 14

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. Advances in computer technology have revolutionized the processing of medical and drug claims. Claims processing i

Options:

A.

Lower

B.

Higher

C.

Same

D.

No change

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Questions 15

The following programs are part of the Alcove MCO's utilization management (UM) program:

  • A telephone triage program
  • Preventive care initiatives
  • A shared decision-making program
  • A self-care program

With regard to the UM programs, it is most likely cor

Options:

A.

self-care program is intended to complement physicians' services, rather than to supercede or eliminate these services

B.

telephone triage program is staffed by physicians only

C.

shared decision-making program is appropriate for virtually any medical condition

D.

preventive care initiatives include immunization programs but not health promotion programs

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Questions 16

PBM plans operate under several types of contractual arrangements. Under one contractual arrangement, the PBM plan and the employer agree on a target cost per employee per month. If the actual cost per employee per month is greater than the target cost, t

Options:

A.

fee-for-service arrangement

B.

risk sharing contract

C.

capitation contract

D.

rebate contract

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Questions 17

The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.

Options:

A.

True

B.

False

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Questions 18

The Courtland PPO maintains computerized records that include clinical, demographic, and administrative data about individual plan members. The data in these records is available to plan providers, ancillary service departments, pharmacies, and others inv

Options:

A.

a data warehouse

B.

a decision support system

C.

an outsourcing system

D.

an electronic medical record (EMR) system

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Questions 19

One of the most influential pieces of legislation in the advancement of managed care within the United States was the HMO Act of 1973. One provision of the HMO Act of 1973 was that it

Options:

A.

emphasized compensating physicians based solely on the volume of medical services they provide

B.

exempted HMOs from all state licensure requirements

C.

established a process under which HMOs could elect to be federally qualified

D.

required federally qualified HMOs to relate premium levels to the health status of the individual enrollee or employer group

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Questions 20

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

Options:

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

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