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AHIP AHM-250 Healthcare Management: An Introduction Exam Practice Test

Demo: 55 questions
Total 367 questions

Healthcare Management: An Introduction Questions and Answers

Question 1

The measures used to evaluate healthcare quality are generally divided into three categories: process, structure, and outcomes. An example of a process measure that can be used to evaluate a health plan's performance is the:

Options:

A.

Percentage of adult plan members who receive regular medical checkups.

B.

Number of plan members contracting an infection in the hospital.

C.

Percentage of board certified physicians within the health plan's network.

D.

Number of hospital admissions for plan members with certain medical conditions.

Question 2

Which of the choices below contains the four tools used by marketers that make up the 'promotion mix'?

Options:

A.

Advertising, personal selling, sales promotion, and publicity.

B.

Advertising, price, sales promotion, and publicity.

C.

Admissions, personal selling, sales promotion, and publicity.

D.

Advertising, personal selling, sales promotion, and privacy.

Question 3

Utilization management techniques that most HMOs use for hospital providers include:

Options:

A.

Discharge planning

B.

Case management

C.

Co-payment for office visits

D.

A & B

Question 4

Common characteristics of POS products are

Options:

A.

Lack of Freedom of choice

B.

Absence of Primary care physician

C.

Cost-cutting efforts and the structure of coverage

D.

All of the above

Question 5

The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential

Options:

A.

An indemnity wraparound plan

B.

A self-funded plan

C.

An aggregate stop-loss plan

D.

A fully funded plan

Question 6

Prescription drug benefits in Medicare can be obtained through:

Options:

A.

Stand alone prescription drug pl (PDPs)

B.

Traditional fee for service (FFS) Medicare

C.

Medicare Advantage pl

D.

Both A & C

Question 7

The Koster Company plans to purchase a health plan for its employees from Intuitive HMO. Intuitive will administer the plan and will bear the responsibility of guaranteeing claim payments by paying all incurred covered benefits. Koster will pay for the he

Options:

A.

fully funded plan

B.

stop-loss plan

C.

self-pay plan

D.

self-funded plan

Question 8

The Stateside Health Plan uses the following outcomes measures to evaluate the quality of its diabetes disease management program.

Measure A: Incidence of foot ulcers among long-term diabetes patients

Measure B: Ability of long-term diabetes patients to m

Options:

A.

Measure A clinical status Measure B patient perception

B.

Measure A clinical status Measure B functional status

C.

Measure A functional status Measure B patient perception

D.

Measure A functional status Measure B clinical status

Question 9

In the CPT system, each service or procedure is identified by

Options:

A.

Three-digit with decimal point

B.

Three-digit

C.

Five-digit with decimal point

D.

Five-digit

Question 10

The following statements are about information management in health plans. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:

Options:

A.

Health plans find EDI useful for transmitting data among different health plan locations.

B.

EDI is different from eCommerce in the EDI is the transfer of data, typically in batches, while ecommerce is a back-and-forth exchange of information concerning individual transactions.

C.

The majority of health plan eCommerce occurs via proprietary computer networks.

D.

Benefits that health plans can receive from using electronic data interchange.

Question 11

The Madison Health Plan, a national MCO, and a local hospital system that operates its own managed healthcare network recently created a new and separate managed healthcare organization, the Pineapple Health Plan. Madison and the hospital system share own

Options:

A.

a consolidation

B.

a joint venture

C.

a merger

D.

an acquisition

Question 12

The Gable MCO sometimes experience-rates small groups by underwriting a number of small groups as if they constituted one large group and then evaluating the experience of the entire large group. This practice, which allows small groups to take advantage

Options:

A.

prospective experience rating

B.

pooling

C.

retrospective experience rating

D.

positioning

Question 13

Which of the following statements is true?

Options:

A.

A declining economy can lead to lower healthcare costs as a result of an older population with greater healthcare needs.

B.

A larger patient population increases pressure on the health plan to offer larger panels.

C.

Provider networks are not affected by the federal and state laws that apply to health plans

D.

Network management standards established by independent accrediting organizations have no influence on health plan network design.

Question 14

When the Knoll Company purchased group health coverage from the Castle Health Maintenance Organization (HMO), the agreement between the two parties specified that the plan would be a typical fully funded plan. Because Knoll had been covered under a previous

Options:

A.

230

B.

270

C.

220

D.

180

Question 15

Which of the following is NOT a preventive care initiative often used by health plans?

Options:

A.

Screening for high blood pressure

B.

Maternity management programs

C.

Vaccines

D.

Physical therapy

Question 16

Certificate of Authority (COA) is subject to:

Options:

A.

Contract between health plan and employer

B.

State laws require an HMO not to be organized as a corporation

C.

Compliance with CMS

D.

an HMO may have to be licensed as an HMO or insurance company in each state in which it conducts business

Question 17

The National Committee for Quality Assurance (NCQA) is a nonprofit organization that accredits health plans and other healthcare organizations. Under the current NCQA accreditation program, a health plan's accreditation score is determined, in part, by pe

Options:

A.

is a performance-measurement tool designed to help healthcare purchasers and consumers compare quality offered by different plans.

B.

divides performance measures into 8 domains, and organizes reporting measures under these domains.

C.

is updated annually and measures are changed or new measures added.

D.

all of the above

Question 18

Which of the following is WRONG?

Options:

A.

Computer Based Patient Records Institute (CPRI) developed the standards for digital imaging of xrays.

B.

HL7 developers focuses on interchange of Clinical Health Data

C.

ANSI, a voluntary national standards organization, creates a consensus based process by which fair and equitable standards can be developed and serves as a legitmizer of standards.

D.

American Health Information Management Association focuses on EDI standards for exchange of clinical data

Question 19

The following statements pertain to the federal requirements for minimum deductible & maximum out of pocket expeses for a high deductible health plan in the year 2006. Select the correct answer from the options given below.

Options:

A.

Minimum deductible - $ 1,050 for self only coverage ; maximum out of pocket expenses- $ 2,100 for self only coverage

B.

Minimum deductible - $ 1,050 for self only coverage ; maximum out of pocket expenses- $ 10.500 for family coverage

C.

Minimum deductible - $ 2,100 for self only coverage ; maximum out of pocket expenses- $ 10,500 for self only coverage

D.

Minimum deductible - $ 2,100 for self only coverage ; maximum out of pocket expenses- $ 5,250 for self only coverage

Question 20

In the following sections, we will describe some of the measures health plans use to evaluate the quality of the services and healthcare they offer their members.

Which of the following is the best description of what a 'Process measure' evaluates?

Options:

A.

The nature, quantity, and quality of the resources that a health plan has available for member service and patient care.

B.

The methods and procedures a health plan and its providers use to furnish service and care.

C.

The extent to which services succeed in improving or maintaining satisfaction and patient health.

D.

None of the above

Question 21

______________ HMOs can't medically underwrite any group – incl small groups.

Options:

A.

State

B.

Not-for-profit

C.

For-profit

D.

Federally qualified

Question 22

Federal Employee Health Benefits Program (FEHBP) requires health plans offering services to federal employees and their dependents to provide

Options:

A.

Immediate access to emergency services

B.

Urgent Appointments within 24 hours

C.

Routine appointments once a m

D.

D

E.

A

F.

B & C

G.

All of the listed options

Question 23

Al Marak, a member of the Frazier Health Plan, has asked for a typical Level One appeal of a decision that Frazier made regarding Mr. Marak's coverage. One true statement about this Level One appeal is that

Options:

A.

Mr. Marak has the right to appeal to the next level if the Level One appeal upholds the original decision

B.

It requires Frazier and Mr. Marak to submit to arbitration in order to resolve the dispute

C.

It is considered to be an informal appeal

D.

It will be handled by an independent review organization (IRO)

Question 24

Before the Leo Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the

Options:

A.

receive compensation based on the volume and variety for medical services they perform for Leo plan members, whereas the specialists receive compensation based solely on the number of plan members who are covered for specific services

B.

have no financial incentive to practice preventive care or to focus on improving the health of their plan members, whereas the specialists have a positive incentive to help their plan members stay healthy

C.

receive from the IPA the same monthly compensation for each Leo plan member under the PCP's care, whereas the specialists receive compensation based on a percentage discount from their normal fees

D.

receive compensation based on a fee schedule, whereas the specialists receive compensation based on per diem charges

Question 25

As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members:

  • Brad Van Note, age 28, is taking many different, costly medications for

Options:

A.

Mr. Van Note, Mr. Albrecht, and Ms. Cromartie

B.

Mr. Van Note and Ms. Cromartie only

C.

Mr. Van Note and Mr. Albrecht only

D.

Mr. Albrecht and Ms. Cromartie only

Question 26

From the following choices, choose the definition that best matches the term health risk assessment (HRA)

Options:

A.

A technique used to educate plan members on how to distinguish between minor problems and serious conditions and effectively treat minor problems themselves

B.

A technique used to determine if a health condition is present even if a member has not experienced symptoms of the problem

C.

A technique in which information about a plan member's health status, personal and family health history, and health-related behaviors is used to predict the member's likelihood of experiencing specific illnesses or injuries

D.

A technique used to evaluate the medical necessity, appropriateness, and cost-effectiveness of healthcare services for a given patient

Question 27

Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called:

Options:

A.

Codes

B.

Lists

C.

Edits

D.

Checks

Question 28

Immediate evaluation and treatment of illness or injury can be provided in any of the following care settings:

Options:

A.

Hospital emergency departments

B.

Physician's offices

C.

Urgent care centers

If these settings are ranked in order of the cost of providing c

D.

A, B, C

E.

A, C, B

F.

B, C, A

G.

C, A, B

Question 29

Because many patients with behavioral health disorders do not require round-the-clock nursing care and supervision, behavioral healthcare services can be delivered effectively in a variety of settings. For example, post-acute care for behavioral health di

Options:

A.

Hospital observation units or psychiatric hospitals.

B.

Psychiatric hospitals or rehabilitation hospitals.

C.

Subacute care facilities or skilled nursing facilities.

D.

Psychiatric units in general hospitals or hospital observation units.

Question 30

In most cases, medical errors are caused by breakdowns in the healthcare system rather than by provider mistakes.

Options:

A.

True

B.

False

Question 31

Greentree Medical, a health plan, is currently recruiting PCPs in preparation for its expansion into a new service area. Abigail Davis, a recruiter for Greentree, has been meeting with Melissa Cortelyou, M.D., in an effort to recruit her as a PCP in Green

Options:

A.

Greentree is prevented by law from offering a contract to Dr. Cortelyou until the credentialing process is complete

B.

any contract signed by Dr. Cortelyou should include a clause requiring the successful completion of the credentialing process within a defined time frame in order for the contract to be effective

C.

Greentree must offer a standard contract to Dr. Cortelyou, without regard to the outcome of the credentialing process

D.

Greentree will abandon the credentialing process now that Dr. Cortelyou has agreed to participate in Greentree's network

Question 32

During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, fo

Options:

A.

the angina, the high blood pressure, and the broken ankle

B.

the angina and the high blood pressure only

C.

none of these conditions

D.

the broken ankle only

Question 33

A medical foundation is a not-for-profit entity that purchases and manages physician practices. In order to retain its not-for-profit status, a medical foundation must

Options:

A.

Provide significant benefit to the community

B.

Employ, rather than contract with, participating physicians

C.

Achieve economies of scale through facility consolidation and practice management

D.

Refrain from the corporate practice of medicine

Question 34

General HMO is building a provider network and is considering Universal Hospital as an addition to its network. Minimum requirements that General should consider in determining whether Universal is qualified to participate in General's network include A.

Options:

A.

Both A and B

B.

A only

C.

B only

D.

Neither A nor B

Question 35

In order to help review its institutional utilization rates, the Sahalee Medical Group, a health plan, uses the standard formula to calculate hospital bed days per 1,000 plan members for the month to date (MTD). On April 20, Sahalee used the following inf

Options:

A.

67

B.

274

C.

365

D.

1,000

Question 36

Health savings accounts were created by which of the following laws:

Options:

A.

COBRA

B.

HIPAA

C.

Medicare Modernization Act

D.

None of the Above

Question 37

Health plans use the following to determine the number of providers to add to a network:

Options:

A.

Staffing ratios

B.

Drive time

C.

Geographic availability

D.

All of the above

Question 38

Ed O'Brien has both Medicare Part A and Part B coverage. He also has coverage under a PBM plan that uses a closed formulary to manage the cost and use of pharmaceuticals. Recently, Mr. O'Brien was hospitalized for an aneurysm. Later, he was transferred by

Options:

A.

Confinement in the extended-care facility after his hospitalization.

B.

Transportation by ambulance from the hospital to the extended-care facility.

C.

Physicians' professional services while he was hospitalized.

D.

physicians' professional services while he was at the extended-care facility.

Question 39

One way in which health plans differ from traditional indemnity plans is that health plans typically

Options:

A.

provide less extensive benefits than those provided under traditional indemnity plans

B.

place a greater emphasis on preventive care than do traditional indemnity plans

C.

require members to pay a percentage of the cost of medical services rendered after a claim is filed, rather than a fixed copayment at the time of service as required by indemnity plans

D.

contain cost-sharing requirements that result in more out-of-pocket spending by members than do the cost-sharing requirements in traditional indemnity plans

Question 40

The Acme HMO recruits and contracts directly with a wide range of physicians—both PCPs and specialists—in its geographic area on a non-exclusive basis. There is no separate legal entity that represents and negotiates the contracts for the physicians. The

Options:

A.

an independent practice association (IPA) model HMO

B.

a staff model HMO

C.

a direct contract model HMO

D.

a group model HMO

Question 41

Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involves

Options:

A.

ascertaining that physicians in the plan have the necessary and appropriate credentials to prescribe medications

B.

compiling data on physician prescribing patterns and comparing physicians' actual prescribing patterns to expected patterns within select drug categories

C.

monitoring patient-specific drug problems through concurrent and retrospective review

D.

establishing protocols that require physicians to obtain certification of medical necessity prior to drug dispensing

Question 42

One of the distinguishing characteristics of healthcare marketing is that many of the markets for health plans are national, not local markets.

Options:

A.

True

B.

False

Question 43

One characteristic of disease management programs is that they typically

Options:

A.

focus on individual episodes of medical care rather than on the comprehensive care of the patient over time

B.

are used to coordinate the care of members with any type of disease, either chronic or nonchronic

C.

focus on managing populations of patients who have a specific chronic illness or medical condition, but do not focus on patient populations who are at risk of developing such an illness or condition

D.

use clinical practice processes to standardize the implementation of best practices among providers

Question 44

Provider integration has two components: operational integration and structural integration. An example of operational integration in health plans is the:

Options:

A.

Acquisition of the Leopard Health Plan by the Hickory Health Plan.

B.

Joint venture entered into by the Eclipse Health Plan and a local hospital system to create a new health plan in which Eclipse and the hospital system share ownership.

C.

Formation of an organization by a group of providers to carry out billing, collections, and contracting with health plans for the entire group of providers.

D.

Consolidation of the Carver Health Plan and the Limestone Health Plan.

Question 45

Merle Spencer has coverage under both Medicare Part A and Medicare Part B. Ms. Spencer recently was hospitalized for chest pains, and she incurred charges for:

  • The cost of hospitalization for two days
  • Diagnostic tests performed in the hospital
  • Trans

Options:

A.

ambulance and the diagnostic tests

B.

ambulance, the diagnostic tests, and the physician's professional services

C.

cost of hospitalization

D.

cost of hospitalization and the physician's professional services

Question 46

One way in which a health plan can support an ethical environment is by

Options:

A.

requiring organizations with which it contracts to adopt the plan's formal ethical policy

B.

developing and maintaining a culture where ethical considerations are integrated into decision making at the top organizational level only

C.

establishing a formal method of managing ethical conflicts, such as using an ethics task force or bioethics consultant

D.

maintaining control of policy development by removing providers and members from the process of developing and implementing policies and procedures that provide guidance to providers and members confronted with ethical issues

Question 47

Phoebe Urich is covered by a traditional indemnity health insurance plan that specifies a $500 calendar-year deductible and includes a 20% coinsurance provision. When Ms. Urich was hospitalized, she incurred $3,000 in medical expenses that were covered by

Options:

A.

1900

B.

2000

C.

2400

D.

2500

Question 48

Member satisfaction is a critical element of a health plan's quality management program. A health plan can obtain information about member satisfaction with various aspects of the health plan from

Options:

A.

surveys completed by members following a visit to a provider

B.

surveys sent to plan members who have not received healthcare services during a specified time period

C.

periodic reports of complaints received by member services personnel

D.

all of the above

Question 49

The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.

Options:

A.

True

B.

False

Question 50

The following programs are part of the Alcove MCO's utilization management (UM) program:

  • A telephone triage program
  • Preventive care initiatives
  • A shared decision-making program
  • A self-care program

With regard to the UM programs, it is most likely cor

Options:

A.

self-care program is intended to complement physicians' services, rather than to supercede or eliminate these services

B.

telephone triage program is staffed by physicians only

C.

shared decision-making program is appropriate for virtually any medical condition

D.

preventive care initiatives include immunization programs but not health promotion programs

Question 51

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. In early efforts to manage healthcare costs, traditional indemnity health insurers included in their health pla

Options:

A.

cost shifting

B.

deductibles

C.

underwriting

D.

copy

Question 52

Primary care case managers (PCCMs) provide case management services to eligible Medicaid recipients. With regard to PCCMs it is correct to say that:

Options:

A.

PCCMs typically receive a case management fee, rather than reimbursement for medical services on a FFS basis, for the services they provide to Medicaid recipients.

B.

All Medicaid recipients who live in rural areas must be given a choice of at least four PCCMs.

C.

PCCMs receive a case management fee in addition to reimbursement for medical services on a FFS basis.

D.

PCCMs contract directly with the federal government to provide case management services to Medicaid recipients.

Question 53

The following programs are part of the Alcove Health Plan's utilization management (UM) program:

  • Preventive care initiatives
  • A telephone triage program
  • A shared decision-making program
  • A self-care program

With regard to the UM programs, it is most

Options:

A.

Preventive care initiatives include immunization programs but not health promotion programs.

B.

Telephone triage program is staffed by physicians only.

C.

Shared decision-making program is appropriate for virtually any medical condition.

D.

Self-care program is intended to complement physicians' services, rather than to supersede or eliminate these services.

Question 54

The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. Advances in computer technology have revolutionized the processing of medical and drug claims. Claims processing i

Options:

A.

Lower

B.

Higher

C.

Same

D.

No change

Question 55

One true statement about community rating, a rating method commonly used by health plans, is that:

Options:

A.

It requires a health plan to set premiums for financing medical care according to the health plan's expected cost of providing medical benefits to a sub-group within the community.

B.

A health plan usually uses community rating to set premiums for large groups.

C.

It tends to lead to greater fluctuations in premium rates than do other rating methods.

D.

A health plan seldom uses community rating to set premiums for large groups.

Demo: 55 questions
Total 367 questions