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Get Certified: Proven Methods to Pass the AHIP AHM-530 Exam

Questions 31

Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in

Options:

A.

Slower access to BH care for plan members

B.

Increased collaboration between BH providers and PCPs

C.

Fewer specialized BH services for plan members

D.

Decreased continuity of BH care for plan members

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Questions 32

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.

Options:

A.

Both 1 and 2

B.

Neither 1 nor 2

C.

1 Only

D.

2 Only

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Questions 33

The Ross Health Plan compensates Dr. Cecile Sanderson on a FFS basis. In order to increase the level of reimbursement that she would receive from Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The services she actually provided represented an intermediate level of service. Dr. Sanderson’s action is an example of a type of false billing procedure known as

Options:

A.

Cost shifting

B.

Churning

C.

Unbundling

D.

Upcoding

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Questions 34

The National Committee for Quality Assurance (NCQA) has integrated accreditation with Health Employer Data and Information Set (HEDIS) measures into a program called Accreditation ’99. One statement that can correctly be made about these accreditation standards is that

Options:

A.

Health plans are required by law to report HEDIS results to NCQA

B.

HEDIS restricts its reporting criteria to a narrow group of quantitative performance measures, while NCQA includes a broad range of qualitative performance measures

C.

Private employer groups purchasing health care coverage increasingly require both NCQA accreditation and HEDIS reporting

D.

HEDIS includes measures of a health plan’s effectiveness of care rather than its cost of care

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Questions 35

From the following answer choices, choose the term that best matches the description.

An integrated delivery system (IDS), which controls most providers in a particular specialty, agrees to provide that specialty service to a health plan only on the condition that the health plan agree to contract with the IDS for other services.

Options:

A.

Group boycott

B.

Horizontal division of territories

C.

Tying arrangements

D.

Concerted refusal to admit

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Questions 36

Network managers rely on a health plan’s claims administration department for much of the information needed to manage the performance of providers who are not under a capitation arrangement. Examining claims submitted to a health plan’s claims administration department enables the health plan to

Options:

A.

determine the number of healthcare services delivered to plan members

B.

monitor the types of services provided by the health plan’s entire provider network

C.

evaluate providers’ practice patterns and compliance with the health plan’s procedures for the delivery of care

D.

all of the above

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Questions 37

The Medea Clinic is a network provider for Delphic Healthcare. Delphic transferred the contract it held with Medea to the Elixir HMO, an entity that was not party to the original contract. The process by which Delphic transferred the contract it held with Medea to Elixir is known as

Options:

A.

Most-favored- nation arrangement

B.

Alimit on action

C.

Aconsideration

D.

An assignment

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Questions 38

The Sweeney Health Plan uses the discounted fee-for-service (DFFS) method to compensate some of its providers. Under this method of compensation, Sweeney calculates payments based on

Options:

A.

The standard fees of indemnity health insurance plans, adjusted by region

B.

The Medicare fee schedules used by other health plans, adjusted by region

C.

Whichever amount is higher, the billed charge or the DFFS amount

D.

Whichever amount is lower, the billed charge or the DFFS amount

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Questions 39

Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be

Options:

A.

$42,857

B.

$56,700

C.

$272,160

D.

$680,400

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Questions 40

The Adobe Health Plan complies with all of the provisions of the Newborns' and Mothers' Health Protection Act (NMHPA) of 1996. Kristen Netzger, an Adobe enrollee, was hospitalized for a cesarean delivery. Amy Davis, also an Adobe enrollee, was hospitalized for a normal delivery. From the following answer choices, select the response that indicates the minimum length of time for which Adobe, under NMHPA, most likely must provide benefits for the hospitalizations of Ms. Netzger and Ms. Davis.

Options:

A.

Ms. Netzger = 48 hours

Ms. Davis = 48 hours

B.

Ms. Netzger = 72 hours

Ms. Davis = 72 hours

C.

Ms. Netzger = 96 hours

Ms. Davis = 48 hours

D.

Ms. Netzger = 96 hours

Ms. Davis = 72 hours

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Exam Code: AHM-530
Exam Name: Network Management
Last Update: Jun 23, 2024
Questions: 202

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