Guaranteed AHM-250 Paper 2021

NEW QUESTION 1

IROs stands for

• A. Internal Review Organizations
• B. International review Organizations
• C. Independent review organizations
• D. None of the above

Answer: C

NEW QUESTION 2

Eleanor Giambi is covered by a typical 24-hour managed care program. One characteristic of this program is that it:

• A. Provides M
• B. Giambi with healthcare coverage for any illness or injury, but only if the cause of the illness or injury is work-related.
• C. Combines the group health plan and disability plan offered by M
• D. Giambi's employer with workers' compensation coverage.
• E. Requires M
• F. Giambi and her employer to each pay half of the cost of this coverage.
• G. Requires M
• H. Giambi to pay specified deductibles and copayments before receiving benefits under this program for any illness or injury.

Answer: B

NEW QUESTION 3

The statements below describe technology used by two MCOs to respond to incoming telephone calls:
✑ The Morton MCO uses an automated system that answers telephone calls with recorded or synthesized speech and prompts the caller to respond to a menu of opt

• A. Autumn's device is best described as an interactive voice response (IVR) system.
• B. Both Morton's system and Autumn's device are applications of computer/telephony
• C. integration (CTI).
• D. Morton's system is best described as an automatic call distributor (ACD).
• E. Morton's system can be correctly characterized as an expert system.

Answer: B

NEW QUESTION 4

From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy

• A. Health plans and their providers are obligated not to harm their members
• B. Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a group
• C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members
• D. Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives

Answer: D

NEW QUESTION 5

The following statements describe healthcare services delivered to health plan members by plan providers. Select the statement that describes a service that would most likely require utilization review and authorization.

• A. Adele Farnsworth visited a dermatologist to have a mole removed from her arm.
• B. Jonathan Lang underwent an electrocardiogram (EKG) during an office visit with his cardiologist.
• C. Corinne Maxwell underwent physical therapy after being hospitalized for hip replacement surgery.
• D. Jose Redriguez, a 70-year-old Medicare patient, received a flu shot as part of his annual physical examination.

Answer: C

NEW QUESTION 6

One true statement regarding ethics and laws is that the values of a community are reflected in

• A. both ethics and laws, and both ethics and laws are enforceable in the court system
• B. both ethics and laws, but only laws are enforceable in the court system
• C. ethics only, but only laws are enforceable in the court system
• D. laws only, but both ethics and laws are enforceable in the court system

Answer: B

NEW QUESTION 7

In 1999, the United States Congress passed the Financial Services Modernization Act, referred to as the Gramm-Leach-Bliley (GLB) Act. The primary provisions included under
the GLB Act require financial institutions, including health plans, to take several

• A. Notify customers of any sharing of non-public personal financial information with nonaffiliated third parties.
• B. Prohibit customers from having the opportunity to 'opt-out' of sharing non-public personal financial information.
• C. Disclose to affiliates, but not to third parties, their privacy policies regarding the sharing of nonpublic personal financial information.
• D. Agree not to disclose personally identifiable financial information or personally identifiable health information.

Answer: A

NEW QUESTION 8

Which of the following is NOT a reason for conducting utilization reviews?

• A. Improve the quality and cost effectiveness of patient care
• B. Reduce unnecessary practice variations
• C. Make appropriate authorization decisions
• D. Accommodate special requirements of inpatient care

Answer: D

NEW QUESTION 9

Paul Gilbert has been covered by a group health plan for two years. He has been undergoing treatment for angina for the past three months. Last week, Mr. Gilbert began a new job and immediately enrolled in his new company's group health plan, which has a

• A. Can exclude coverage for treatment of M
• B. Gilbert's angina for one year, because HIPAA does not impact a group health plan's pre-existing condition provision.
• C. Can exclude coverage for treatment of M
• D. Gilbert's angina for one year, because M
• E. Gilbert did not have at least 36 months of creditable coverage under his previous health plan.
• F. Can exclude coverage for treatment of M
• G. Gilbert's angina for three months, because that is the length of time he received treatment for this medical condition prior to his enrollment in the new health plan.
• H. Cannot exclude his angina as a pre-existing condition, because the one-year pre- existing condition provision is offset by at least one year of continuous coverage under his previous health plan.

Answer: D

NEW QUESTION 10

Immediate evaluation and treatment of illness or injury can be provided in any of the following care settings:

• A. Hospital emergency departments
• B. Physician's offices
• C. Urgent care centersIf these settings are ranked in order of the cost of providing c
• D. A, B, C
• E. A, C, B
• F. B, C, A
• G. C, A, B

Answer: B

NEW QUESTION 11

Mr. George Bush is covered by a PBM plan that uses a closed formulary. This indicates that

• A. he can receive coverage for pharmaceuticals only if they are on the PBM plan's preferred list of drugs
• B. he must receive all of his pharmaceuticals from a mail-order pharmacy program
• C. he can receive coverage for pharmaceuticals that are on the PBM plan's preferred list of drugs, as well as for pharmaceuticals that are not on the preferred list
• D. the PBM plan cannot receive a rebate on any pharmaceuticals it obtains from the pharmaceutical facture

Answer: A

NEW QUESTION 12

One ethical principle in health plans is the principle of non-malfeasance, which holds that health plans and their providers:

• A. Should allocate resources in a way that fairly distributes benefits and burdens among the members.
• B. Have a duty to present information honestly and are obligated to honor commitments.
• C. Are obligated not to harm their members.
• D. Should treat each plan member in a manner that respects his or her goals and values.

Answer: C

NEW QUESTION 13

Merle Spencer has coverage under both Medicare Part A and Medicare Part B. Ms. Spencer recently was hospitalized for chest pains, and she incurred charges for:
✑ The cost of hospitalization for two days
✑ Diagnostic tests performed in the hospital
✑ Trans

• A. ambulance and the diagnostic tests
• B. ambulance, the diagnostic tests, and the physician's professional services
• C. cost of hospitalization
• D. cost of hospitalization and the physician's professional services

Answer: D

NEW QUESTION 14

Which of the following statements is NOT a requirement for a service to be deemed a 'medically necessary service'?

• A. Furnished in the least intensive type of medical care setting required by the member's condition.
• B. Solely for the convenience of the member.
• C. In accordance with the standards of good medical practice.
• D. Consistent with the symptoms of the member's condition.

Answer: B

NEW QUESTION 15

The contract between an employer and an insurer or other TPA is called

• A. Claims
• B. Bond
• C. ASO
• D. None of the above

Answer: C

NEW QUESTION 16

Beginning in the early 1980s, several factors contributed to increased demand for behavioral healthcare services. These factors included

• A. increased stress on individuals and families
• B. increased availability of behavioral healthcare services
• C. greater awareness and acceptance of behavioral healthcare issues
• D. all of the above

Answer: D

NEW QUESTION 17

The provision of mental health and chemical dependency services is collectively known as behavioral healthcare. The following statements are about behavioral healthcare. Select the answer choice containing the correct statement.

• A. In most preferred provider organizations (PPOs) and open access plans, plan members must receive a referral before accessing behavioral healthcare services from a specialist.
• B. To manage the delivery of behavioral healthcare services, managed behavioral health organizations (MBHOs) typically use alternative treatment levels and alternative treatment methods rather than crisis intervention or alternative treatment settings.
• C. Managed behavioral health organizations (MBHOs) typically are prohibited from negotiating with network providers for reduced fees in exchange for increased patient volume.
• D. The treatment approaches for behavioral healthcare most often include drug therapy, psychotherapy, and counseling.

Answer: B

NEW QUESTION 18

The Venus Hospital provides medical care to paying patients, as well as to people who either have no healthcare coverage and cannot pay for the care by themselves or who receive services at reduced rates because they are covered under government sponsored

• A. anti selection
• B. cost shifting
• C. receivership
• D. underwriting

Answer: B

NEW QUESTION 19

The following statements apply to flexible spending arrangements. Select the answer choice that contains the correct statement.

• A. FSAs were designed to help increase health insurance coverage among self-employed individuals.
• B. Only employers may contribute funds to FSAs.
• C. The popularity of FSAs has been limited because funds may not be rolled over from
• D. year to year.
• E. A popular feature of FSAs is their portability, which allows employees to take the funds with them when they change jobs.

Answer: C

NEW QUESTION 20

In 1999, the United States Congress passed the Financial Services Modernization Act, which is referred to as the Gramm-Leach-Bliley (GLB) Act. The following statement(s) can correctly be made about this act:

• A. The GLB Act allows convergence among the transaction
• B. A only
• C. Both A and B
• D. B only
• E. Neither A nor B

Answer: B

NEW QUESTION 21

The existing committees at the Majestic Health Plan, a health plan that is subject to the requirements of HIPAA, include the Executive Committee and the Corporate Compliance Committee. The Executive Committee serves as a long-term advisory body on issues

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: B

NEW QUESTION 22

Each time a patient visits a provider he has to pay a fixed dollar amount?

• A. Deductible
• B. Copayment
• C. Capitation
• D. Co-insurance

Answer: B

NEW QUESTION 23

Prescription drug benefits in Medicare can be obtained through:

• A. Stand alone prescription drug pl (PDPs)
• B. Traditional fee for service (FFS) Medicare
• C. Medicare Advantage pl
• D. Both A & C

Answer: A

NEW QUESTION 24

The Koster Company plans to purchase a health plan for its employees from Intuitive HMO. Intuitive will administer the plan and will bear the responsibility of guaranteeing claim payments by paying all incurred covered benefits. Koster will pay for the he

• A. fully funded plan
• B. stop-loss plan
• C. self-pay plan
• D. self-funded plan

Answer: A

NEW QUESTION 25

Medicaid is a jointly funded federal and state program that provides hospital and medical expense coverage to low-income individuals and certain aged and disabled individuals. One characteristic of Medicaid is that

• A. providers who care for Medicaid recipients must accept Medicaid payment as payment in full for services rendered
• B. Medicaid requires recipients to pay deductibles, copayments, and coinsurance amounts for all services
• C. Medicaid is always the primary payer of benefits
• D. benefits offered by Medicaid programs are federally mandated and do not vary by state

Answer: A

NEW QUESTION 26

As part of its quality management program, the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. When Lyric concludes that its competitor's practices or services are better than its own, Lyric im

• A. Benchmarking.
• B. Standard of care.
• C. An adverse event.
• D. Case-mix adjustment.

Answer: A

NEW QUESTION 27

The following statements are about federal laws that affect healthcare organizations. Select the answer choice containing the correct response.

• A. The Women's Health and Cancer Rights Act (WHCRA) of 1998 requires health plans to offer mastectomy benefits.
• B. The Health Care Quality Improvement Act (HCQIA) requires hospitals, group practices, and HMOs to comply with all standard antitrust legislation, even if these entities adhere to due process standards that are outlined in HCQIA.
• C. The Newborns' and Mothers' Health Protection Act (NMHPA) of 1996 mandates that coverage for hospital stays for childbirth must generally be a minimum of 24 hours for normal deliveries and 48 hours for cesarean births.
• D. Although the Mental Health Parity Act (MHPA) does not require health plans to offer mental health coverage, it imposes requirements on those plans that do offer mental health benefits.

Answer: D

NEW QUESTION 28

The Oriole MCO uses a typical diagnosis-related groups (DRGs) payment method to reimburse the Isle Hospital for its treatment of Oriole members. Under the DRG payment method, whenever an Oriole member is hospitalized at Isle, Oriole pays Isle

• A. an amount based on the weighted value of each medical procedure or service that Isle provides, and the weighted value is determined by the appropriate current procedural terminology (CPT) code for the procedure or service
• B. a fixed rate based on average expected use of hospital resources in a given geographical area for that DRG
• C. a retrospective reimbursement based on the actual costs of the Oriole member's hospitalization
• D. a specific negotiated amount for each day the Oriole member is hospitalized

Answer: B

NEW QUESTION 29

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 you have selected.
The Harbor Health Plan convened a litigation

• A. a standing / ongoing
• B. a standing / specific
• C. an ad hoc / ongoing
• D. an ad hoc / specific

Answer: D

NEW QUESTION 30

One way in which a health plan can support an ethical environment is by

• A. requiring organizations with which it contracts to adopt the plan's formal ethical policy
• B. developing and maintaining a culture where ethical considerations are integrated into decision making at the top organizational level only
• C. establishing a formal method of managing ethical conflicts, such as using an ethics task force or bioethics consultant
• D. maintaining control of policy development by removing providers and members from the process of developing and implementing policies and procedures that provide guidance to providers and members confronted with ethical issues

Answer: C

NEW QUESTION 31
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