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

Questions 41

The following statements are about health plans’ use of electronic data interchange (EDI). Three of the statements are true and one is false. Select the answer choice containing the FALSE ALSE statement.

Options:

A.

One advantage of EDI over manual data management systems is improved data integrity.

B.

EDI may use the Internet as the communication link between the participating parties.

C.

EDI involves back-and-forth exchanges of information concerning individual transactions.

D.

The data format for EDI is agreed upon by the sending and receiving parties.

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Questions 42

The Hall Health Plan gathered objective clinical information about the recommended uses and dosages of angiotensin-converting enzyme (ACE) inhibitors and presented the information to network providers to illustrate the appropriate use of these frequently prescribed and expensive drugs. This information indicates that Hall most likely educated its network providers through the use of

Options:

A.

detailing

B.

cognitive services

C.

counter detailing

D.

drug efficacy study implementation (DESI)

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Questions 43

One method of transferring the information in electronic medical records (EMRs) is through a health information network (HIN). The following statements are about HINs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

Options:

A.

A HIN may afford a health plan better measurements of outcomes and provider performance.

B.

The use of a HIN typically increases a health plan’s exposure to liability for poor care.

C.

Most HINs are Internet-based rather than built on proprietary computer networks.

D.

Currently, the majority of health plans do not have HINs that are capable of transferring medical records among their network providers.

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Questions 44

The case management program director at the Nova Health Plan calculated the program’s ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:

Administrative costs for case management ..........$40,000

Actual medical care expenses for patients under case management ..........$680,000

Projected medical care expenses for the same patients without case management ..........$900,000

This information indicates that, for the previous quarter, Nova’s ratio of medical expense savings to case management administrative costs was

Options:

A.

0.71/1

B.

0.80/1

C.

5.50/1

D.

1.25/1

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Questions 45

With respect to the activities of MCO medical directors, it is correct to say that medical directors typically perform all of the following activities EXCEPT

Options:

A.

maintaining clinical practices

B.

delivering performance feedback to providers

C.

participating in utilization management (UM) activities

D.

educating other MCO staff about new clinical developments or provider innovations that might impact clinical practice management

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Questions 46

The Midwest Health Plan delegated utilization review (UR) activities to the Tri-City Utilization Review Organization. After Tri-City improperly recommended denial of payment for services to a Midwest plan member, the plan member filed suit. The court ruled that Midwest was responsible for Tri-City’s actions because of the relationship between Midwest and Tri-City. This situation is an illustration of a legal concept known as

Options:

A.

vicarious liability

B.

fraud

C.

a tying arrangement

D.

subdelegation

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Questions 47

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

Due to competitive pressures and consumer demand, many health plans now offer direct access or open access products. Under a direct access product, a member is (required / not required) to select a primary care provider (PCP), and is (required / not required) to obtain a referral from a PCP or the health plan before visiting a network specialist.

Options:

A.

required / required

B.

required / not required

C.

not required / required

D.

not required / not required

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Questions 48

Medicare beneficiaries can obtain healthcare benefits through fee-for-service (FFS) Medicare programs, Medicare medical savings account (MSA) plans, Medigap insurance, or coordinated care plans (CCPs). Unlike other coverage options, CCPs

Options:

A.

provide only those benefits covered by Medicare Part A and Part B

B.

are not subject to federal or state regulation

C.

place primary care at the center of the delivery system

D.

are structured as indemnity plans

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Exam Code: AHM-540
Exam Name: Medical Management
Last Update: Jun 16, 2024
Questions: 163

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