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Your Path to Success: How to Pass the AHIP AHM-540 Medical Management Exam

Questions 11

The nature of behavioral healthcare creates unique medical management challenges for health plans. One method health plans have used to support the delivery of appropriate services in a cost-effective manner is to

Options:

A.

remove behavioral healthcare services from the primary care setting

B.

shift behavioral healthcare from acute inpatient settings to alternative settings when feasible

C.

reserve the use of psychotherapy for treatment of those conditions that persist over long periods of time or for the life of the patient

D.

offer the same level of compensation to all of the professional disciplines that provide behavioral healthcare services to plan members

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Questions 12

The Brighton Health Plan regularly performs prospective UR for surgical procedures. Brighton’s prospective UR activities are likely to include

Options:

A.

documenting the clinical details of the patient’s condition and care

B.

tracking the length of inpatient stay

C.

completing the discharge planning process

D.

determining the most appropriate setting for the proposed course of care

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Questions 13

Among this agency’s accreditation programs are accreditation for preferred provider organizations (PPOs), health plan call centers, and case management organizations. This agency classifies its standards as either “shall” standards or “should” standards.

Options:

A.

American Accreditation HealthCare Commission/URAC (URAC)

B.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

C.

Community Health Accreditation Program (CHAP)

D.

National Committee for Quality Assurance (NCQA)

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Questions 14

Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans typically use home healthcare include

1. The period prior to a hospital admission

2. The period following discharge from a hospital

Options:

A.

Both 1 and 2

B.

1 only

C.

2 only

D.

Neither 1 nor 2

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Questions 15

The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through

1. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

2. The National Committee for Quality Assurance (NCQA)

3. The American Accreditation HealthCare Commission/URAC (URAC)

Options:

A.

All of the above

B.

1 and 2 only

C.

2 and 3 only

D.

1 only

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Questions 16

This agency oversees the Federal Employee Health Benefits Program (FEHBP).

Options:

A.

Health Resources and Services Administration (HRSA)

B.

Office of Personnel Management (OPM)

C.

Department of Health and Human Services (HHS)

D.

Department of Justice (DOJ)

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Questions 17

The BBA of 1997 allows states to provide Medicaid benefits to children through the State Children’s Health Insurance Program (SCHIP). Under the terms of the BBA, states can implement SCHIP as

1. Part of their existing Medicaid programs

2. Separate commercial insurance programs

Options:

A.

Both 1 and 2

B.

1 only

C.

2 only

D.

Neither 1 nor 2

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Questions 18

Determine whether the following statement is true or false:

The delegation of medical management functions to providers can occur without the transfer of financial risk.

Options:

A.

True

B.

False

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Questions 19

Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.

The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.

Greenhouse’s prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).

Options:

A.

open / mandatory

B.

open / voluntary

C.

closed / mandatory

D.

closed / voluntary

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Questions 20

The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self-care most likely would not be appropriate.

Options:

A.

Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area.

B.

Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day.

C.

Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility.

D.

Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.

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Exam Code: AHM-540
Exam Name: Medical Management
Last Update: Jul 25, 2024
Questions: 163

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