AHIP AHM-530 Exam Questions Instant Access

Question 1

With respect to contractual provisions related to provider-patient communications, nonsolicitation clauses prohibit providers from

AEncouraging patients to switch from one health plan to another

BDisclosing confidential information about the health plan's reimbursement structure

CDispersing confidential financial information regarding the health plan

DDiscussing alternative treatment plans with patients

Answer : A

Question 2

As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy CMS requirements regulating access to covered services. In order to ensure that its network provides adequate access, Brightwell must

AAllow enrollees to determine whether they will receive primary care from a physician, nurse practitioner, or other qualified network provider

BBase a provider's participation in the network, reimbursement, and indemnification levels on the provider's license or certification

CDefine its service area according to community patterns of care

DRequire enrollees to obtain prior authorization for all emergency or urgently needed services

Answer : C

Question 3

In contracting with providers, a health plan can use a closed panel or open panel approach. One statement that can correctly be made about an open panel health plan is that the participating providers

Amust be employees of the health plan, rather than independent contractors

Bare prohibited from seeing patients who are members of other health plans

Ctypically operate out of their own offices

Doperate according to their own standards of care, rather than standards of care established by the health plan

Answer : C

Question 4

Grant Pelham is covered by both a workers' compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.

The provider network that Shipwright uses to furnish services for its workers' compensation program will most likely

AEmphasize primary care and consist mostly of generalists

BFocus treatment approaches on rapid recovery rather than cost

COffer workers' compensation beneficiaries the same types and levels of treatment that Shipwright's traditional network furnishes to group health plan members

DExempt participating providers from meeting standard credentialing requirements

Answer : B

Question 5

The Octagon Health Plan includes a typical indemnification clause in its provider contracts. The purpose of this clause is to require Octagon's network providers to

AAgree not to sue or file claims against an Octagon plan member for covered services

BReimburse Octagon for costs, expenses, and liabilities incurred by the health plan as a result of a provider's actions

CMaintain the confidentiality of the health plan's proprietary information

DAgree to accept Octagon's payment as payment in full and not to bill members for anything other than contracted copayments, coinsurance, or deductibles

Answer : B

Question 6

One true statement about the compensation arrangement known as the case rate system is that, under this system,

AProviders stand to gain or lose based on the number and types of treatments used for each case

BProviders have no incentives to take an active role in managing cost and utilization

CPayors cannot adjust standard case rates to reflect the severity of the patient's condition or complications that arise from multiple medical problems

DPayors have the opportunity to benefit from the provider's cost savings

Answer : A

Question 7

After HIPAA was enacted, Congress amended the law to include the Mental Health Parity Act (MHPA) of 1996, a federal requirement relating to mental health benefits. One true statement about the MHPA is that it

Arequires all health plans to provide coverage for mental health services

Brequires health plans to carve out mental/behavioral healthcare from other services provided by the plans

Callows health plans to require patients receiving mental health services to pay higher copayments than patients seeking treatment for physical illnesses

Dprohibits health plans that offer mental health benefits from applying more restrictive limits on coverage for mental illness than on coverage for physical illness

Answer : D

AHIP Network Management AHM-530 Exam Questions