Question 1

Determine whether the following statement is true or false: The key to successfully managing the quality and cost-effectiveness of healthcare services for Medicaid enrollees is to merge Medicaid recipients into existing plans.

Accepted Answer

While merging Medicaid recipients into existing plans may be one approach to managing quality and cost-effectiveness, it is not the only key to success. Other strategies may include payment reform, care coordination, and utilization management. Additionally, merging into existing plans could lead to issues with access and adequacy of services for Medicaid enrollees.

Question 2

Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the

Accepted Answer

The answer of Access to services is an important issue...

Question 3

The following statements are about chronic and disabling conditions among children eligible for Medicaid. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

Accepted Answer

The statement that the majority of chronic conditions affecting children in Medicaid programs are the same as those affecting children in the general population is false. In fact, children in Medicaid programs are more likely to have complex and severe chronic conditions compared to the general population.

Question 4

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. Ways that workers' compensation health plans can help control the costs of job-related injuries and illnesses include

Accepted Answer

The answer of For this question, if answer choices (A)...

Question 5

To see that utilization guidelines are consistently applied, UR programs rely on authorizationsystems. Determine whether the following statement about authorization systems is true or false:IT Certification Guaranteed, The Easy Way!3Instant Download - Best Exam Practice Material - 100% Money Back Guarantee!Get Latest & Valid AHM-540 Exam's Question and Answers from Examstorrent.com. 3 ;http://www.examstorrent.com/ahm-540-exam-dumps-torrent.htmlOnly physicians can make nonauthorization decisions based on medical necessity.

Accepted Answer

Authorization systems are designed to ensure that utilization guidelines are consistently applied. However, only physicians have the authority to make nonauthorization decisions based on medical necessity.

Question 6

In most health plans, the formulary system is developed and managed by a P&T committee. The ;P&T committee is responsible for;

Accepted Answer

The P&T committee is primarily responsible for evaluating and selecting drugs for inclusion in the formulary. The other tasks listed (overseeing manufacture, distribution, and marketing of drugs or certifying medical necessity of expensive, potentially toxic, or nonformulary drugs) are typically not within the purview of the P&T committee.

Question 7

With respect to the activities of MCO medical directors, it is correct to say that medicaldirectors typically perform all of the following activities EXCEPT

Accepted Answer

The passage states that medical directors typically perform all of the listed activities EXCEPT maintaining clinical practices. Therefore, option A is the correct answer as medical directors are not responsible for maintaining clinical practices.

Question 8

Occasionally, employers combine workers' compensation, group healthcare, and disability programs into an integrated product known as 24-hour coverage. One true statement about 24- hour coverage is that it typically

Accepted Answer

24-hour coverage allows plans to apply disability management and return-to-work techniques to nonoccupational conditions, which can improve overall health outcomes and reduce long-term disability costs. This type of integrated coverage also streamlines the administrative process for both the employer and the employee, reducing costs and increasing efficiency. It does not exempt plans from complying with state workers' compensation regulations and does not necessarily require separate databases of patient care information, as data can be integrated into a single system.

Question 9

The following statements describe situations in which health plan members have medicalproblems that require care. Select the statement that describes a situation in which self-care mostlikely would not be appropriate.

Accepted Answer

Avis Bennet's symptoms indicate a potential infection, which would require medical attention beyond self-care measures. The other statements describe situations where self-care or ongoing medical management is appropriate for the medical condition.

Question 10

The following statement(s) can correctly be made about medical management considerations for the Federal Employee Health Benefits Program (FEHBP): 1. FEHBP plan members who have exhausted the health plan's usual appeals process for a disputed decision can request an independent review by the Office of Personnel Management (OPM) 2. All health plans that cover federal employees are required to develop and implement patient safety initiatives

Accepted Answer

Both statements are correct. Statement 1 describes the appeals process for FEHBP plan members, while statement 2 describes a requirement for all health plans covering federal employees.

Question 11

Health plans communicate proposed performance changes through action statements. Selectthe answer choice containing an action statement that includes all of the required elements.

Accepted Answer

The action statement (increase proportion of children under age two who are up-to-date on immunizations by seven percent within one year) includes the required elements: a specific population (children under age two), a measurable outcome (proportion up-to-date on immunizations), a timeframe (one year), and a specific performance change (increase by seven percent).

Question 12

The delivery of quality, cost-effective healthcare is a primary goal of both group healthcareand workers' compensation programs. One difference between group healthcare and workers'compensation is that workers' compensation

Accepted Answer

Workers' compensation provides coverage for a variety of direct and indirect healthcare, disability, and workplace costs, regardless of fault, which is a key difference from group healthcare programs.

Question 13

Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located at a military installation. Ms. Wilson serves as a primary point of contact between enrollees and the TRICARE system and answers enrollees' questions about plan options, eligibility, provider selection, and claims. This information indicates that Ms. Wilson serves as a

Accepted Answer

The description of Serena Wilson's role indicates that she is serving as a beneficiary services representative, as she is the primary point of contact between enrollees and the TRICARE system to answer questions about plan options, eligibility, provider selection, and claims. The other options (lead agent, health plan support contractor, primary care manager) do not accurately describe her role based on the information given.

Exam 1: AHM Medical Management