Ace the AHIP AHM-520 Exam: Ultimate Preparation Guide

The provider reimbursement trend probably is more difficult for Wisteria to quantify than is the residual trend

Wisteria's residual trend is the difference between the total trend and the portion of the total trend caused by changes in Wisteria's provider reimbursement levels

The residual trend most likely has more impact on Wisteria's total trend than does the provider reimbursement trend

An example of a residual trend would be a 5% increase in the capitation rate paid to a PCP by Wisteria

State laws and regulations in the United States govern the implementation of GAAP, but not the implementation of SAP

Health plans must prepare their financial statements for their external users according to applicable laws, regulations, and accounting principles, particularly GAAP

GAAP specifically focuses on the requirements of insurance regulators and policyholder interests

The Financial Accounting Standards Board (FASB) is a private organization whose purpose is to establish and promote SAP in the United States

The most common reimbursement method for hospitals is professional services capitation

Most jurisdictions prohibit hospitals and physicians from joining together to receive global capitations that cover institutional services provided by the hospitals

Ahealth plan typically can capitate a hospital for outpatient laboratory and X-ray services only if the health plan also capitates the hospital for inpatient care

Many hospitals have formed physician hospital organizations (PHOs), hospital systems, or integrated delivery systems (IDSs) that can accept global capitation payments from health plans

vary only on the factors that affect Fiesta's costs

are at a level that balances Fiesta's need to generate a profit against its need to obtain or retain a specified share of the market in which it conducts business

are high enough to ensure that Fiesta has enough money on hand to pay operating expenses as they come due

do not exceed what Fiesta needs to cover its costs and provide the plan with a fair profit

All of the diagnostic tests that he ordered on Ms. Pfeiffer

His visits to Ms. Pfeiffer while she was hospitalized

The cost of the services that the specialist performed for Ms. Pfeiffer

All of the above

Has only one potential source of funding: borrowing money

Does not pay federal, state, or local taxes on its earnings

Must distribute its earnings to its owners-investors for their personal gain

Is a privately held corporation

The federal government provides none of the funding for state Medicaid programs

Federal Medicaid law is different from Medicare law in that the federal government explicitly sets forth the methodology for payment of Medicaid-contracting plans but not Medicare-contracting plans

A state's payment to health plans for providing Medicaid services cannot be more than it would have cost the state to provide the services under Medicaid fee-for-service (FFS)

States are prohibited from carving out specific services from the capitation rate that health plans receive for providing Medicaid services

Cash Inflows – Cash Outflows = Net Cash Inflow (Outflow)

Revenues – Expenses = Net Income (Net Loss)

Sources of Funds – Uses of Funds = Net Change in Cash

Assets = Liabilities + Owners' Equity

A sliding scale per-diem charges arrangement differs from a sliding scale discount on charges arrangement in that only a sliding scale per-diem charges arrangement is based on total volume of admissions and outpatient procedures.

Under a typical reimbursement arrangement that is based on diagnosisrelated groups (DRGs), if the payment amount is fixed on the basis of diagnosis, then any reduction in costs resulting from a reduction in days will go to the health plan rather than to the hospital.

A negotiated straight per-diem charge requires payment of a single charge for a day in the hospital, regardless of any actual charges or costs incurred during the hospital stay.

A straight discount on charges arrangement is the most common reimbursement method in markets with high levels of health plans.

The cost of maintaining the trust may be prohibitive to Jasmine

The trust must always maintain enough assets to pay the health plan's claims that have been incurred but not yet paid

Jasmine is prohibited from earning any return on the trust assets

The contributions to this trust are not deductible for federal income tax purposes