All About Practical AHM-530 Actual Exam

NEW QUESTION 1

The following statements are about the negotiation process of provider contracting. Three of the statements are true and one of the statements is false. Select the answer choice containing the FALSE statement.

• A. While preparing for negotiations, the health plan usually sends the provider an application to join the provider network, a list of credentialing requirements, and a copy of the proposed provider contract, which may or may not include the proposed reimbursement schedule.
• B. In general, the ideal negotiating style for provider contracting is a collaborative approach.
• C. Typically, the health plan and the provider negotiate the reimbursement arrangement between the parties before they negotiate the scope of services and the contract language.
• D. The actual signing of the provider contract typically takes place after negotiations are completed.

Answer: C

NEW QUESTION 2

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.
One statement that can correctly be made about Gardenia’s two-level POS product is that

• A. members who self-refer without first seeing their PCPs will receive no benefits
• B. both Gardenia and the PCPs stand to benefit if the non-provider panels are kept relatively narrow
• C. members will pay higher coinsurance or copayments if they first see their PCPs each time
• D. the plan offers no financial incentives to members to choose an in-network specialist over a non-network specialist

Answer: D

NEW QUESTION 3

Member satisfaction surveys help an health plan determine whether its providers are consistently delivering services to plan members in a manner that lives up to member expectations. Member satisfaction surveys allow the health plan to gather information about

• A. Amember’s reaction to services received during a specific encounter
• B. The reactions of specific subsets of the health plan’s membership
• C. Members’ positive and negative experience with the plan’s services
• D. All of the above

Answer: D

NEW QUESTION 4

The Sweeney Health Plan uses the discounted fee-for-service (DFFS) method to compensate some of its providers. Under this method of compensation, Sweeney calculates payments based on

• A. The standard fees of indemnity health insurance plans, adjusted by region
• B. The Medicare fee schedules used by other health plans, adjusted by region
• C. Whichever amount is higher, the billed charge or the DFFS amount
• D. Whichever amount is lower, the billed charge or the DFFS amount

Answer: D

NEW QUESTION 5

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

• 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

Answer: C

NEW QUESTION 6

In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it

• A. Applies to group health insurance plans only
• B. Limits the length of a health plan’s pre-existing condition exclusion period for a previously covered individual to a maximum of six months after enrollment.
• C. Guarantees access to healthcare coverage for small businesses and previously covered individuals who meet specified eligibility requirements.
• D. Guarantees renewability of group and individual health coverage, provided the insureds are still in good health

Answer: C

NEW QUESTION 7

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service
(DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:

• A. D
• B. Enberg's young patients receive appropriate immunizations at the right ages
• C. D
• D. Enberg's young patients receive appropriate immunizations at the right ages
• E. The condition of one of D
• F. Enberg's patients improved after the patient received medical treatment from D
• G. Enberg
• H. D
• I. Enberg's procedures are adequate for ensuring patients' access to medical care

Answer: A

NEW QUESTION 8

The following situations illustrate violations of federal antitrust laws:
Situation A Two HMOs split a large employer group by agreeing to let one HMO market to some company employees and to let the second HMO market to different company employees.
Situation B Members of a physician-hospital organization (PHO) that has significant market share jointly agreed to exclude a physician from joining the PHO solely because that physician has admitting privileges at a competing hospital.
From the following answer choices, select the response that best identifies the types of violations illustrated by these situations:

• A. Situation A: horizontal division of territories; Situation B: group boycott
• B. Situation A: horizontal division of territories; Situation B: exclusive arrangement
• C. Situation A: exclusive arrangement; Situation B: group boycott
• D. Situation A: exclusive arrangement; Situation B: tying arrangement

Answer: A

NEW QUESTION 9

The Crimson Health Plan, a competitive medical plan (CMP), has entered into a Medicare risk contract. One true statement about Crimson is that, as a:

• A. CMP, Crimson is regulated by the federal government under the terms of the Tax Equity and Fiscal Responsibility Act (TEFRA)
• B. CMP, Crimson is not allowed to charge a Medicare enrollee a premium for any additional benefits it provides over and above Medicare benefits
• C. Provider under a Medicare risk contract, Crimson receives for its services a capitated payment equivalent to 85% of the AAPCC
• D. Provider under a Medicare risk contract, Crimson is required to deliver to members all Medicare-covered services, without regard to the cost of those services

Answer: D

NEW QUESTION 10

Reimbursement for prescription drugs and services in a third-party prescription drug plan typically follows one of two approaches: a reimbursement approach or a service approach. One true statement about these approaches is that:

• A. Payments under the reimbursement method typically are not subject to any copayment or deductible requirements
• B. Payments under the reimbursement approach are typically based on a structured reimbursement schedule rather than on usual, customary, and reasonable (UCR) charges
• C. Most major medical plans follow a service approach
• D. Most current health plan prescription drug plans are service plans

Answer: D

NEW QUESTION 11

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. A credentials verification organization (CVO) can be certified to verify certain pertinent credentialing information, including

• A. Liability claims histories of prospective providers
• B. Hospital privileges of prospective providers
• C. Malpractice insurance on prospective providers
• D. All of the above

Answer: D

NEW QUESTION 12

One type of fee schedule payment system assigns a weighted unit value for each medical procedure or service based on the cost and intensity of that service. Under this system, the unit values for procedural services are generally higher than the unit values for cognitive services. This system is known as a

• A. Wrap-around payment system
• B. Relative value scale (RVS) payment system
• C. Resource-based relative value scale (RBRVS) system
• D. Capped fee system

Answer: B

NEW QUESTION 13

Factors that are likely to indicate increased health plan market maturity include:

• A. Increased consolidation among health plans.
• B. Increased rate of growth in health plan premium levels.
• C. Areduction in the market penetration of HMO and point-of-service (POS) products.
• D. Areduction in the frequency of performance-based reimbursement of providers.

Answer: A

NEW QUESTION 14

From the following answer choices, choose the type of clause or provision described in this situation.
The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.

• A. Cure provision
• B. Hold-harmless provision
• C. Evergreen clause
• D. Exculpation clause

Answer: C

NEW QUESTION 15

The following statements are about some of the issues surrounding the contractual responsibilities of health plans. Select the answer choice containing the correct statement.

• A. Typically, health plans are required to pay completed claims within 10 days of submission.
• B. Health plans typically are prohibited from examining the financial soundness of a self- funded employer plan that relies on the health plan to pay providers for services received by the plan’s members.
• C. Patient delivery is one of the most significant factors that health plans consider when determining whether provider services should be reimbursed on a capitated or fee-for- service (FFS) basis.
• D. Health plans require all providers to agree to an exclusive provider contract.

Answer: C

NEW QUESTION 16
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