Deck 1: AHM Medical Management

Question 1

Private employers are key purchasers of health plan services. The following statement(s) can correctly be made about employer expectations about the quality and cost- effectiveness of healthcare services: 1. For both health maintenance organizations (HMOs) and non-HMO plans, employers typically have access to accreditation results and performance measurement reports to help them evaluate the quality of healthcare and service 2. Because of employers concern about the quality and costs of healthcare services available through health plans, direct contracting has become a dominant model among employers who sponsor health benefit programs for their employees

A) Both 1 and 2
B) 1 only
C) 2 only
D) Neither 1 nor 2

Answer 1

D

Question 2

The paragraph below contains an incomplete statement. Select the answer choice containingthe term that correctly completes the paragraph.Medical management programs often require the analysis of many types of data and information.__________________ is an automated process that analyzes variables to help detect patterns andrelationships in the data.

A) Unbundling
B) Outsourcing
C) Data mining
D) Drilling down

Answer 2

C

Question 3

Nilay Sharma suffered a small wound while working in his yard and was taken to a local hospital for treatment. A triage nurse at the hospital evaluated Mr. Sharmas condition and directed him to an outpatient unit in the hospital where a physician assistant examined, cleaned, and sutured the wound. Mr. Sharma returned home following treatment. The care Mr. Sharma received at the hospital is an example of the type of care known as

A) specialty referral
B) primary prevention
C) urgent care
D) emergency care

Answer 3

C

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.The QAPI (Quality Assessment Performance Improvement Program) is a Centers for Medicaid andMedicare Services (CMS) initiative designed to strengthen health plans' efforts to protect andimprove the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standardsapply to

A) standard medical-surgical services
B) mental health and substance abuse services
C) services offered to Medicare enrollees as optional supplementary benefits
D) all of the above

Question 5

The following statements are about risk management for case management. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A) The use of a signed consent authorization form is consistent with accrediting agency standards for patient privacy and confidentiality of medical information.
B) Case management that is initiated after a member has incurred substantial medical expenses is more likely to be viewed as a tool to cut costs rather than to improve outcomes.
C) Health plan documents indicating that any case management delegates are separate, independent entities may reduce an health plan's exposure to risk.
D) A case management file cannot be used to support the health plan's position in the event of a lawsuit.

Question 6

Some health plans administer a questionnaire known as the Behavioral Risk Factor SurveillanceSystem (BRFSS) as part of their health risk assessment (HRA) processes. The following statements areabout the BRFSS. If statements (A) through (C) are all correct, select answer choice (D). Otherwise,select the one correct statement.

A) This questionnaire was designed specifically for use by health plans.
B) Each health plan must use the same form of the questionnaire, with no additions or modifications.
C) This questionnaire monitors the prevalence of the major behavioral risks associated with illnessand injury among adults.
D) All of the above statements are correct

Question 7

Determine whether the following statement is true or false: The delegation of medical management functions to providers can occur without the transfer of financial risk.

A) true
B) false
C) True and False
D) No one

Question 8

The following statement(s) can correctly be made about accrediting agency standards for delegation: 1. The National Committee for Quality Assurance (NCQA) allows health plans to delegate all medical management functions, including the responsibility to perform delegation oversight activities 2. In some cases, accreditation standards for delegation oversight are reduced if the delegate has already been certified or accredited by the delegators accrediting agency

A) Both 1 and 2
B) 1 only
C) 2 only
D) Neither 1 nor 2

Question 9

Many health plans use clinical pathways to help manage the delivery of acute care services to plan members. One true statement about clinical pathways is that they

A) determine which healthcare services are medically necessary and appropriate for a particular patient in a particular situation
B) outline the services that will be delivered, the providers responsible for delivering the services, the timing of delivery, the setting in which services are delivered, and the expected outcomes of the interventions
C) cover only services delivered in an acute inpatient setting
D) address medical conditions that affect a small segment of a given population and with which the majority of providers are unfamiliar

Question 10

Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute. If Ms. Stanley agrees to the generic substitution, she will receive a drug that

A) has not been tested for safety and efficacy in large clinical trials
B) is available without a prescription at a reasonable cost
C) has been classified by the Food and Drug Administration (FDA) as safe, but that has not been proven fully effective
D) contains active ingredients that are identical to those of the prescribed brand-name drug

Question 11

The Strathmore Health Plan uses clinical pathways to manage its acute care services. In order to reduce the risk of financial liability associated with the use of clinical pathways, Strathmore and its network hospitals should

A) base pathways on relevant evidence reported in medical literature
B) restrict each pathway to a single medical condition
C) use pathways to establish a new standard of care
D) allow providers to use only those interventions listed in the pathways

Question 12

The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Select the term or phrase in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms or phrases you have chosen. TRICARE enrollees have the right to challenge authorization and coverage decisions. Such challenges are referred to as (appeals / grievances) and are typically handled by the (TRICARE contractor / Area Field Office).

A) appeals / TRICARE contractor
B) appeals / Area Field Office
C) grievances / TRICARE contractor
D) grievances / Area Field Office

Question 13

Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute. 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 that you have chosen. Greenhouses prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).

A) open / mandatory
B) open / voluntary
C) closed / mandatory
D) closed / voluntary

Question 14

Among this agencys accreditation programs are accreditation for preferred provider organizations (PPOs), health plan call centers, and case management organizations. This agency classifies its standards as either shall standards or should standards.

A) American Accreditation HealthCare Commission/URAC (URAC)
B) Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
C) Community Health Accreditation Program (CHAP)
D) National Committee for Quality Assurance (NCQA)

Question 15

To measure performance for quality management, health plans collect and analyze three typesof data: financial data, clinical data, and customer satisfaction data. The following statement(s) cancorrectly be made about the sources of clinical data:1.Patient surveys are the most widely used source of disease-specific clinical information2.Outcomes research studies sponsored by academic institutions and professional organizations havelimited usefulness for particular health plans or individual providers3.The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys address both physical and mentalhealth status

A) All of the above
B) 1 and 2 only
C) 2 and 3 only
D) 3 only

Question 16

Since its inception, Medicare has undergone a number of changes because of legal andregulatory action. One result of the Balanced Budget Act (BBA) of 1997 has been to

A) expand Medicare benefits by mandating coverage for certain preventive services
B) reduce the number of organizations that can deliver covered services
C) encourage growth of managed Medicare programs in all markets
D) increase the number of "zero premium" plans available to Medicare beneficiaries

Question 17

Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services

A) must be offered as separate supplemental benefits or separate products
B) lack clinical trials to evaluate their safety and effectiveness
C) are not covered by state or federal consumer protection statutes
D) focus on a specific illness, injury, or symptom rather than on the whole body

Question 18

Most health plans require a PCP referral or precertification for CAM benefits.

A) true
B) false
C) True and False
D) No one

Question 19

Selene Varga is participating in her health plans disease management program for congestive heart failure. Ms. Vargas health status is regularly monitored and managed by a licensed nurse who visits Ms. Varga at her home to administer treatment and assess the need for changes in Ms. Vargas overall care plan. This information indicates that Ms. Varga is participating in the type of disease management program known as a

A) coordinated outreach model program
B) case management model program
C) hub-and-spoke model program
D) group clinic model program

Question 20

A health plans coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions: 1.In case of conflict between the purchaser contract and a health plans medical policy or benefits administration policy, the contract takes precedence 2.Purchaser contracts commonly exclude custodial care from their coverage of services and supplies 3.All of the criteria for coverage decisions must be included in the purchaser contract

A) All of the above
B) 1 and 2 only
C) 2 only
D) 3 only

Question 21

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.

Question 22

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

A) lack of qualified providers in provider networks
B) lack of resources necessary to establish case management programs for patients with complex conditions
C) unstable eligibility status of Medicaid recipients
D) inability of Medicaid recipients to change health plans or PCPs

Question 23

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.

A) Children with chronic conditions use more physician and nonphysician professional services than do children in the general population.
B) The majority of chronic conditions affecting children in Medicaid programs are the same as those affecting children in the general population.
C) Medicaid-eligible children are at risk for seriousmental and physical conditions.
D) Children in Medicaid programs have a higher incidence of chronic disabling conditions than do children in the general population.

Question 24

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

A) applying strict definitions of medical necessity
B) developing prevention and recovery programs
C) applying out-of-network benefit reductions

Question 25

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.

Question 26

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

A) evaluating and selecting drugs for inclusion in the formulary
B) overseeing the manufacture, distribution, and marketing of prescription drugs
C) certifying the medical necessity of expensive, potentially toxic, or nonformulary drugs
D) all of the above

Question 27

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

A) maintaining clinical practices
B) delivering performance feedback to providers
C) participating in utilization management (UM) activities
D) educating other MCO staff about new clinical developments or provider innovations that mightimpact clinical practice management

Question 28

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

A) increases administrative costs
B) requires plans to maintain separate databases of patient care information
C) exempts plans from complying with state workers' compensation regulations
D) allows plans to apply disability management and return-to-work techniques to nonoccupational conditions

Question 29

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.

A) Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increasedand that there are red streaks and swelling around the bruised area.
B) Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times eachday.
C) Caroline Evans has severe arthritis that requires regular exercise and oral medication to reducepain and help her maintain mobility.
D) Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.

Question 30

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

A) Both 1 and 2
B) 1 only
C) 2 only
D) Neither 1 nor 2

Question 31

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

A) The proportion of adult members who are screened for hypertension will increase by ten percent.
B) Primary care providers (PCPs) will increase the proportion of children under the age of two whoare up-to-date on immunizations by seven percent within one year.
C) The QM program director will evaluate the level of provider compliance with clinical practiceguidelines (CPGs).
D) The disease management program director will increase participation by asthmatic children in thehealth plan's pediatric asthma disease management program.

Question 32

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

A) provides health and disability benefits to employees injured on the job only if the employer is atfault for the injury
B) provides coverage for a variety of direct and indirect healthcare, disability, and workplace costs
C) manages costs by including employee cost-sharing features in its benefit design
D) places limits on benefits by restricting the amount of benefit payments or the number of coveredhospital days or provider office visits

Question 33

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

A) lead agent
B) beneficiary services representative
C) health plan support contractor
D) primary care manager (PCM)