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

Questions 1

The following activities are the responsibility of either the Nova Health Plan's risk management department or its medical management department:

Options:

A.

Protecting Nova's members against harm from medical care

B.

Improving the overall health status of Nova members by coordinating care across individual episodes of care and the different providers who treat the member

C.

Protecting Nova against financial loss associated with the delivery of healthcare

D.

Establishing outreach programs to encourage the use of preventive health services by Nova's members of these activities, the ones that are more likely to be the responsibility of Nova's risk management department rather than its medical management department are activities:

E.

A, B, and C

F.

A, C, and D

G.

A and C

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Questions 2

If a member of the Green Health Plan reasonably believes that a provider in Green's provider network was acting as Green's employee or agent while providing negligent care, then the member may have cause to bring action against the health plan. This legal concept is known as vicarious liability. Steps that Green can take to reduce its exposure to vicarious liability claims include:

Options:

A.

Placing restrictions on provider-member communication involving treatment decisions.

B.

Implementing risk management and quality assurance programs for its provider network.

C.

Including in its provider agreements and marketing and membership literature a statement that members of the Green provider network are not independent contractors.

D.

All of the above.

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Questions 3

Before or during the orientation process, health plans generally provide new network providers with a provider manual. One of the primary purposes of the provider manual is to

Options:

A.

Provide a directory of contracted providers

B.

Help providers and their staffs develop methods of improving the operation of their practices

C.

Provide feedback to providers regarding their performance

D.

Reinforce and document contractual provisions

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Questions 4

Dr. Ahmad Shah and Dr. Shantelle Owen provide primary care services to Medicare+Choice enrollees of health plans under the following physician incentive plans:

Dr. Shah receives $40 per enrollee per month for providing primary care and an additional $10 per enrollee per month if the cost of referral services falls below a specified level

Dr. Owen receives $30 per enrollee per month for providing primary care and an additional $15 per enrollee per month if the cost of referral services falls below a specified level

The use of a physician incentive plan creates substantial risk for

Options:

A.

Both Dr. Shah and Dr. Owen

B.

Dr. Shah only

C.

Dr. Owen only

D.

Neither Dr. Shah nor Dr. Owen

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Questions 5

The following statements are about Medicaid health plan entities. Select the answer choice containing the correct statement:

Options:

A.

To keep Medicaid enrollment costs as low as possible, states typically prohibit the use of third-party entities known as enrollment brokers to handle the recruitment and enrollment of Medicaid recipients in health plan plans

B.

Primary care case managers (PCCMs) are individuals who contract with a state's Medicaid agency to provide primary care services mainly to urban areas.

C.

Typically, Medicaid beneficiaries must be given a choice between at least two health plan entities.

D.

Medicaid health plan entities are responsible for providing primary coverage for all dually-eligible beneficiaries.

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Questions 6

The following statements describe two types of HMOs:

The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.

The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.

Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.

Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:

The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents per tablet for this drug.

The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.

To calculate its drug costs, Elm uses a pricing system known as:

Options:

A.

Estimated acquisition cost (EAC)

B.

Package rate cost (PRC)

C.

Actual acquisition cost (AAC)

D.

Wholesale acquisition cost (WAC)

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Questions 7

With regard to the compensation of dental care providers in a managed dental care system, it is correct to state that, typically:

Options:

A.

dental PPOs compensate dentists on a capitated basis

B.

group model dental HMOs (DHMOs) compensate general dental practitioners on a salaried basis

C.

independent practice association (IPA)-model dental HMOs (DHMOs) capitate general dental practitioners

D.

staff model dental HMOs (DHMOs) compensate dentists on an FFS basis

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Questions 8

The Ventnor Health Plan requires the physicians in its provider network to be board certified. Ventnor has received requests to become a part of the network from the following specialists:

Cheryl Stovall, who is currently in the process of completing a residency in her field of specialization.

Thomas Kalil, who has completed a residency in his field of specialization and has passed a qualifying examination in that field within two years of completing his residency.

Roger Todd, who has completed a residency in his field of specialization but has not passed a qualifying examination in that field.

Ventnor's requirement of board certification is met by:

Options:

A.

Cheryl Stovall, Thomas Kalil, and Roger Todd.

B.

Thomas Kalil and Roger Todd only.

C.

Thomas Kalil only.

D.

None of these individuals.

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Questions 9

In order to evaluate and manage the performance of individual providers in its provider network, the Quorum Health Plan implemented a program that focuses on identifying the best and worst outcomes and utilization patterns of its providers. This program is also designed to develop and implement strategies such as treatment protocols and practice guidelines to improve the performance of Quorum's providers. This information indicates that Quorum implemented a program known as:

Options:

A.

An integrated delivery system (IDS)

B.

A coordinated care program

C.

Ostensible agency

D.

Continuous quality improvement (CQI)

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Questions 10

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.

In most states, a health plan can be held responsible for a provider’s negligent malpractice. This legal concept is known as (vicarious liability / risk sharing). One step that health plans can take to reduce their exposure to malpractice lawsuits is to state in health plan-provider agreements, marketing collateral, and membership literature that the providers are (employees of the health plan / independent contractors).

Options:

A.

Vicarious liability / employees of the health plan

B.

Vicarious liability / independent contractors

C.

Risk sharing / employees of the health plan

D.

Risk sharing / independent contractors

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Exam Code: AHM-530
Exam Name: Network Management
Last Update: Jun 25, 2024
Questions: 202

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