AHIP AHM-530 Exam Questions Instant Access

Question 1

One reason that an health plan would want to use the actual acquisition cost (AAC) pricing system to calculate its drug costs is that, of the systems commonly used to calculate drug costs, the AAC system

AProvides the lowest level of cost for the health plan

BMost closely represents what pharmacies are actually charged for prescription drugs

COffers the best control over multiple-source pharmaceutical products

DIs the least expensive pricing system for the health plan to implement

Answer : A

Question 2

A provider contract describes the responsibilities of each party to the contract. These responsibilities can be divided into provider responsibilities, health plan responsibilities, and mutual obligations. Mutual obligations typically include

Aprovisions for marketing the plan's product

Bpayment arrangements between the plan and the provider

Cverification of the plan's eligibility to do business

Dmanagement of the contents of members' medical records

Answer : B

Question 3

The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.

The per diem reimbursement method will require Gladspell to pay Ellysium a

AFixed rate for each day a plan member is treated in Ellysium's subacute care facility

BDiscounted charge for all subacute care services given by Ellysium

CRate that varies depending on patient category

DFixed rate per enrollee per month

Answer : A

Question 4

The National Association of Insurance Commissioners (NAIC) Managed Care Plan Network Adequacy Model Act defines specific adequacy and accessibility standards that health plans must meet. In addition, the Model Act requires health plans to

AHold plan members responsible for unreimbursed charges or unpaid claims

BAllow providers to develop their own standards of care

CAdhere to specified disclosure requirements related to provider contract termination

DFile written access plans and sample contracts with the Centers for Medicaid and Medicare Services (CMS)

Answer : C

Question 5

The Omni Health Plan is interested in expanding the specialty services it offers to its plan members and is considering contracting with the following providers of specialty services:

The Apex Company, a managed vision care organization (MVCO)

The Baxter Managed Behavioral Healthcare Organization (MBHO)

The Cheshire Dental Health Maintenance Organization (DHMO)

As part of its credentialing process, Omni would like to verify that each of these providers has met NCQA's accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for

AApex and Baxter only

BApex and Cheshire only

CBaxter and Cheshire only

DBaxter only

Answer : D

Question 6

Dr. Eve Barlow is a specialist in the Amity Health Plan's provider network. Dr. Barlow's provider contract with Amity contains a typical most-favored-nation arrangement. The purpose of this arrangement is to

ARequire Dr. Barlow and Amity to use arbitration to resolve any disputes regarding the contract

BSpecify that the contract is to be governed by the laws of the state in which Amity has its headquarters

CRequire Dr. Barlow to charge Amity her lowest rate for a medical service she has provided to an Amity plan member, even if the rate is lower than the price negotiated in the contract

DState that the contract creates an employment or agency relationship, rather than an independent contractor relationship, between Dr. Barlow and Amity

Answer : C

Question 7

Stop-loss insurance is designed to protect physicians who face substantial financial risk as a result of physician incentive plans. Medicare + Choice health plans must ensure that a physician has adequate stop-loss protection if the

Aphysician has a patient panel that exceeds 25,000 patients

Bphysician receives a bonus that is based solely on quality of care, patient satisfaction, or physician participation

Cdifference between the physician's maximum potential payments and his or her minimum potential payments is less than 25% of the maximum potential payments

Dphysician is subject to a withhold that is greater than 25% of his or her potential payments

Answer : D

AHIP Network Management AHM-530 Exam Questions