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Master the Medical Management AHM-540 Exam with Confidence!

Questions 1

The following statement(s) can correctly be made about the hospitalist approach to inpatient care management:

1. Management of inpatient care by hospitalists may significantly reduce the length of stay and the total costs of care for a hospital admission

2. Most health plans that use hospitalists do so through a voluntary hospitalist program

3. A hospitalist’s familiarity with utilization management (UM) and quality management (QM) standards for inpatient care may reduce unnecessary variations in care and improve clinical outcomes

Options:

A.

All of the above

B.

1 and 2 only

C.

1 and 3 only

D.

2 only

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Questions 2

One way that health plans evaluate their UR programs is by monitoring utilization rates. By definition, utilization rates typically

Options:

A.

indicate changes in the total amount of medical expenses or claim dollars paid for particular procedures

B.

measure the number of services provided per 1,000 members per year

C.

indicate standard approaches to care for many common, uncomplicated healthcare services

D.

report the number of times that a particular provider performs or recommends a service excluded from the benefit plan

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Questions 3

Many health plans use HRA to target their preventive care programs to the healthcare needs of their members. With regard to HRA, it is correct to say that

Options:

A.

Health plans rarely delegate HRA activities to external entities

B.

Health plans typically focus their HRA efforts on newly enrolled members

C.

HRA focuses on clinical data for an entire population and does not include demographic information that might identify individual members

D.

HRA is generally a reliable predictor of medical resource utilization

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Questions 4

The following statements are about health plans' complaint resolution procedures (CRPs). Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

Options:

A.

An health plan's CRPs reduce the likelihood of errors in decision making.

B.

CRPs typically provide for at least two levels of appeal for formal appeals.

C.

CRPs include only formal appeals and do not apply to informal complaints.

D.

Most complaints are resolved without proceeding through the entire CRP process.

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Questions 5

MCOs usually have a formal program for the oversight of delegated activities. The following statements concern typical delegation oversight programs. Select the answer choice containing the correct statement.

Options:

A.

A letter of intent is the contractual document that describes the delegated functions and the responsibilities of the MCO and the delegate.

B.

In most cases, the evaluation of a candidate for delegation is based entirely on the candidate’s application and supporting documentation and does not include an on-site assessment of the candidate.

C.

Under most delegation agreements, an MCO cannot terminate the agreement before the end date stated in the agreement.

D.

One objective for a delegation oversight program is to integrate any delegated activities into the MCO’s overall programs for medical management and other functions.

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Questions 6

Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide should Mr. Farrell become incapacitated.

The document that Mr. Farrell is using to communicate his end-of-life healthcare wishes to his family is known as a

Options:

A.

medical power of attorney

B.

patient assessment and care plan

C.

living will

D.

healthcare proxy

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Questions 7

Patricia McLeod is a member of the Enterprise Health Plan, which operates in State X. Ms. McLeod is scheduled to undergo a unilateral mastectomy for the treatment of breast cancer. The surgical procedure will be performed by Dr. Kim Lee, a surgical oncologist. Based on Enterprise’s medical policy, the contract with the purchaser, and Ms. McLeod’s medical condition, Enterprise’s UR staff have determined that the appropriate course of care for Ms.

McLeod includes a 24-hour stay in the hospital following her surgery. State X, however, has a benefit mandate specifying health plan coverage for 48 hours of inpatient post-mastectomy care. In this situation, the length of hospital stay for which Enterprise must offer coverage is

Options:

A.

the length of stay deemed appropriate by Dr. Lee

B.

the 24-hour stay determined to be appropriate by Enterprise’s UR staff

C.

the length of stay deemed appropriate by Ms. McLeod

D.

the 48-hour length of stay specified by State X

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Questions 8

In order for a health plan’s performance-based quality improvement programs to be effective, the desired outcomes must be

Options:

A.

achievable within a specified timeframe

B.

defined in terms of multiple results

C.

expressed in subjective, qualitative terms

D.

all of the above

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Questions 9

In order to be effective, a clinical pathway must improve quality and decrease costs.

Options:

A.

True

B.

False

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Questions 10

The Fairview Health Plan uses a dual database approach to integrate information needed for its disease management program. This information indicates that Fairview uses an information management system that

Options:

A.

combines all existing information from all data sources into a single comprehensive system

B.

connects multiple databases with a central interface engine that acts as an information clearinghouse

C.

provides an outside vendor with pertinent data that the vendor compiles into an integrated database

D.

creates a separate database that pulls pertinent information from the health plan’s claims database, formats the information for easy analysis, and stores it in the separate database

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Exam Code: AHM-540
Exam Name: Medical Management
Last Update: Jun 15, 2024
Questions: 163

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