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Ace the AHIP AHM-250 Exam: Ultimate Preparation Guide

Questions 81

Health plans require utilization review for all services administered by its participating physicians.

Options:

A.

True

B.

False

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Questions 82

Historically most HMOs have been

Options:

A.

Closed-access HMO

B.

Closed-panel HMO

C.

Open-access HMO

D.

Open-panel HMO

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Questions 83

Before an HMO contracts with a physician, the HMO first verifies the physician's credentials.

Upon becoming part of the HMO's organized system of healthcare, the physician is typically subject to

Options:

A.

both recredentialing and peer review

B.

recredentialing only

C.

peer review only

D.

neither recredentialing nor peer review

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Questions 84

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

Options:

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

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Questions 85

Bart Vereen is insured by both a traditional indemnity health insurance plan, which is his primary plan, and a managed care plan. Both plans have a typical coordination of benefits (COB) provision, but neither plan has a nonduplication of benefits provision

Options:

A.

380

B.

130

C.

0

D.

550

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Questions 86

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

Options:

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

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Questions 87

Consumer-directed health plans are not a new concept. They actually got their start in the late 1970s with the advent of:

Options:

A.

Health savings accounts (HSAs)

B.

Health reimbursement arrangements (HRAs)

C.

Medical savings accounts (MSAs)

D.

Flexible spending arrangements (FSAs)

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Questions 88

Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.

Options:

A.

The Serenity Healthcare Organization requires a plan member or the provider in charge of the member's care to obtain authorization for inpatient care before the member is admitted to the hospital.

B.

UR nurses employed by the Friendship Health Plan monitor length of stay to identify factors that might contribute to unnecessary hospital days.

C.

The Optimum Health Group evaluates the medical necessity and appropriateness of proposed services and intervenes, if necessary, to redirect care to a more appropriate care setting.

D.

The Axis Medical Group examines provider practice patterns to identify areas in which services are being underused, overused, or misused and designs strategies to prevent inappropriate utilization in the future.

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Questions 89

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

Options:

A.

the use of physician practice guidelines

B.

the requirement of copayments for office visits

C.

capitation

D.

risk pools

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Questions 90

Health plans can organize under a not-for-profit form or a for-profit form. One true statement regarding not-for-profit health plans is that these organizations typically

Options:

A.

are exempt from review by the Internal Revenue Service (IRS)

B.

are organized as stock companies for greater flexibility in raising capital

C.

rely on income from operations for the large cash outlays needed to fund long-term projects and expansion

D.

engage in lobbying or political activities in order to maintain their tax-exempt status

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