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AHIP AHM-530 Network Management Exam Practice Test

Demo: 30 questions
Total 202 questions

Network Management Questions and Answers

Question 1

The following statements are about network management for behavioral healthcare (BH). Three of these statements are true and one statement is false. Select the answer choice containing the FALSE statement.

Options:

A.

Two measures of BH quality are patient satisfaction and clinical outcomes assessments.

B.

For a health plan, one argument in favor of contracting with a managed behavioral healthcare organization (MBHO) is that the health plan's members can gain faster access to BH care.

C.

In their contracts with health plans, managed behavioral healthcare organizations (MBHOs) usually receive delegated authority for network development and management.

D.

Health plans generally compensate managed behavioral healthcare organizations (MBHOs) on an FFS basis.

Question 2

Prior to the enactment of the Balanced Budget Act (BBA) of 1997, payment for Medicare-covered primary and acute care services was based on the adjusted average per capita cost (AAPCC). The AAPCC is defined as the

Options:

A.

average cost of services delivered to all patients living in a specified geographic region

B.

actuarial value of the deductible and coinsurance amounts for basic Medicare-covered benefits

C.

fee-for-service amount that the Centers for Medicaid and Medicare Services (CMS) would pay for a Medicare beneficiary, adjusted for age, sex, and institutional status

D.

average fixed monthly fee paid by all Medicare enrollees in a specified geographic region

Question 3

The provider contract that Dr. Laura Cartier has with the Sailboat health plan includes a section known as the recitals. Dr. Cartier's contract includes the following statements:

Options:

A.

A statement that identifies the purpose of the contract

B.

A statement that defines in legal terms the parties to the contract

C.

A statement that identifies the Sailboat products to be covered by the contract

Of these statements, the ones that are likely to be included in the recitals section of Dr. Cartier's contract are statements:

D.

A, B, and C

E.

A and B only

F.

A and C only

G.

B and C only

Question 4

The provider contract that the Danube Health Plan has with the Viola Home Health Services Organization states that Danube will use a typical flat rate reimbursement arrangement to compensate Viola for the skilled nursing services it provides to Danube’s plan members. A portion of the contract’s reimbursement schedule is shown below:

Home Health Licensed Practical Nurse (LPN): $45 per visit or $90 per diem

Home Health Registered Nurse (RN): $50 per visit or $110 per diem

Last month, an LPN from Viola visited a Danube plan member and provided 1½ hours of home healthcare, and an RN from Viola visited another Danube plan member and provided 7 hours of home healthcare. The following statement(s) can correctly be made about Danube’s payment to Viola for these services:

Options:

A.

Danube most likely owes $90 for the LPN’s skilled nursing services and $110 for the RN’s skilled nursing services.

B.

Danube’s payment amount could be different from the amount called for in the reimbursement schedule if the level of care provided to one of these plan members was significantly different from the level of care normally provided by Viola’s RNs and LPNs.

C.

Both A and B

D.

A only

E.

B only

F.

Neither A nor B

Question 5

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.

During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.

The report that helped Canyon determine how well Dr. Enberg met the health plan's standards is known as:

Options:

A.

An encounter report

B.

An external standards report

C.

Aprovider profile

D.

An access to care report

Question 6

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.

Mr. Pelham’s group health insurance plan and workers’ compensation both provide benefits to cover expenses incurred as a result of illness or injury. However, unlike traditional group insurance coverage, workers’ compensation

Options:

A.

Provides reimbursement for lost wages

B.

Requires employees who suffer a work-related illness or injury to obtain care from specified network providers

C.

Covers all injuries and illnesses, regardless of their cause

D.

Requires employees to share the cost of treatment through deductible, coinsurance, and benefit limits

Question 7

The following statements are about the organization of network management functions of health plans. Select the answer choice containing the correct response:

Options:

A.

Compared to a large health plan, a small health plan typically has more integration among its network management activities and less specialization of roles.

B.

It is usually more efficient to have a large health plan's provider relations representatives located in the health plan's corporate headquarters rather than based in regional locations that are close to the provider offices the representatives cover.

C.

An health plan's provider relations representatives are usually responsible for conducting an initial orientation of providers and educating providers about health plan developments, rather than recruiting and assisting with the selection of new providers.

D.

In general, a health plan that uses a centralized approach for some of its network management activities should not use a decentralized approach for other network management activities.

Question 8

One characteristic of the workers' compensation program is that:

Options:

A.

workers' compensation coverage is available to all employees, regardless of their eligibility for health insurance coverage

B.

indemnity benefits currently account for less than 10% of all workers' compensation benefits

C.

workers' compensation programs in most states require eligible employees to obtain medical treatment only from members of a provider network

D.

workers' compensation programs include deductibles and coinsurance requirements

Question 9

Martin Breslin, age 72 and permanently disabled, is classified as dually-eligible. This information indicates that Mr. Breslin qualifies for coverage by both

Options:

A.

Medicare and private indemnity insurance, and Medicare provides primary coverage

B.

Medicare and Medicaid, and Medicare provides primary coverage

C.

Medicaid and private indemnity insurance, and Medicaid provides primary coverage

D.

Medicare and Medicaid, and Medicaid provides primary coverage

Question 10

Medicaid beneficiaries pose a challenge for health plans attempting to establish Medicaid provider networks. Compared to membership in commercial health plans, Medicaid enrollees typically

Options:

A.

Require access to greater numbers of obstetricians and pediatricians

B.

Have stronger relationships with primary care providers

C.

Are less reliant on emergency rooms as a source of first-line care

D.

Need fewer support and ancillary services

Question 11

Member satisfaction surveys help an health plan determine whether its providers are consistently delivering services to plan members in a manner that lives up to member expectations. Member satisfaction surveys allow the health plan to gather information about

Options:

A.

Amember’s reaction to services received during a specific encounter

B.

The reactions of specific subsets of the health plan’s membership

C.

Members’ positive and negative experience with the plan’s services

D.

All of the above

Question 12

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.

During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.

The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan member for covered services is known as:

Options:

A.

Atermination with cause clause

B.

Ahold-harmless clause

C.

An indemnification clause

D.

Acorrective action clause

Question 13

One true statement about the Employee Retirement Income Security Act of 1974 (ERISA) is that:

Options:

A.

ERISA applies to all issuers of health insurance products, such as HMOs

B.

pension plans and employee welfare plans are exempt from any regulation under ERISA

C.

ERISA requires self-funded plans to comply with all state mandates affecting health insurance companies and health plans

D.

the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plans

Question 14

A health plan that delegates designated credentialing activities to an NCQA-centered or a Commission/URAC-centered credentials verification organization (CVO) is exempt from the due-diligence oversight requirements specified in the NCQA credentialing standards for all verification services for which the CVO has been certified:

Options:

A.

True

B.

False

Question 15

Before or during the orientation process, health plans generally provide new network providers with a provider manual. One of the primary purposes of the provider manual is to

Options:

A.

Provide a directory of contracted providers

B.

Help providers and their staffs develop methods of improving the operation of their practices

C.

Provide feedback to providers regarding their performance

D.

Reinforce and document contractual provisions

Question 16

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

Options:

A.

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

B.

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

C.

Maintain the confidentiality of the health plan’s proprietary information

D.

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

Question 17

With respect to hiring practices, one step that a health plan most likely can take to avoid violating the terms of the Americans with Disabilities Act (ADA) is to

Options:

A.

Require a medical examination prior to accepting an application for employment

B.

Include in the employment application questions pertaining to health status

C.

Make a conditional offer of employment, and then require the candidate to have an examination prior to granting specific staff privileges

D.

Require applicants to answer questions pertaining to the use of drugs and alcohol

Question 18

The provider contract between the Regal Health Plan and Dr. Caroline Quill contains a type of termination clause known as termination without cause. One true statement about this clause is that it

Options:

A.

Requires Regal to send a report to the appropriate accrediting agency if the health plan terminates Dr. Quill’s contract without cause

B.

Requires that Regal must base its decision to terminate Dr. Quill’s contract on clinical criteria only

C.

Allows either Regal or Dr. Quill to terminate the contract at any time, without any obligation to provide a reason for the termination or to offer an appeals process

D.

Allows Regal to terminate Dr. Quill’s contract at the time of contract renewal only, without any obligation to provide a reason for the termination or to offer an appeals process

Question 19

The Aegean Health Plan delegated its utilization management (UM) program to the Silhouette IPA. Silhouette, in turn, transferred authority for case management to Brandon Health Services. In this situation, Brandon is best described as the

Options:

A.

delegator, and Aegean is ultimately responsible for Brandon’s performance

B.

delegator, and Silhouette is ultimately responsible for Brandon’s performance

C.

subdelegate, and Aegean is ultimately responsible for Brandon’s performance

D.

subdelegate, and Silhouette is ultimately responsible for Brandon’s performance

Question 20

The Ross Health Plan compensates Dr. Cecile Sanderson on a FFS basis. In order to increase the level of reimbursement that she would receive from Ross, Dr. Sanderson submitted the code for a comprehensive office visit. The services she actually provided represented an intermediate level of service. Dr. Sanderson’s action is an example of a type of false billing procedure known as

Options:

A.

Cost shifting

B.

Churning

C.

Unbundling

D.

Upcoding

Question 21

Network managers rely on a health plan’s claims administration department for much of the information needed to manage the performance of providers who are not under a capitation arrangement. Examining claims submitted to a health plan’s claims administration department enables the health plan to

Options:

A.

determine the number of healthcare services delivered to plan members

B.

monitor the types of services provided by the health plan’s entire provider network

C.

evaluate providers’ practice patterns and compliance with the health plan’s procedures for the delivery of care

D.

all of the above

Question 22

In open panel contracting, there are several types of delivery systems. One such delivery system is the faculty practice plan (FPP). One likely result that a health plan will experience by contracting with an FPP is that the health plan will

Options:

A.

be able to select most of the physicians in the FPP

B.

achieve the highest level of cost effectiveness possible

C.

experience limited control over utilization

D.

achieve the most effective case management possible

Question 23

Some states have enacted any willing provider laws. From the perspective of the health plan industry, one drawback of any willing provider laws is that they often result in a reduction of a plan’s

Options:

A.

Premium rates

B.

Ability to monitor utilization

C.

Number of primary care providers (PCPs)

D.

Number of specialists and ancillary providers

Question 24

By definition, a measure of the extent to which a health plan member can obtain necessary medical services in a timely manner is known as

Options:

A.

Network management

B.

Quality

C.

Cost-effectiveness

D.

Accessibility

Question 25

Jay Mercer is covered under his health plan’s vision care plan, which includes coverage for clinical eye care but not for routine eye care. Recently, Mr. Mercer had a general eye examination and got a prescription for corrective lenses. Mr. Mercer’s vision care plan will cover.

Options:

A.

both the general eye examination and the prescription for corrective lenses

B.

the general eye examination only

C.

the prescription for corrective lenses only

D.

neither the general eye examination nor the prescription for corrective lenses

Question 26

One reimbursement method that health plans can use for hospitals is the ambulatory payment classifications (APCs) method. APCs bear a resemblance to the diagnosis-related groups (DRGs) method of reimbursement. However, when comparing APCs and DRGs, one of the primary differences between the two methods is that only the APC method

Options:

A.

is typically used for outpatient care

B.

assigns a single code for treatment

C.

applies to treatment received during an entire hospital stay

D.

is considered to be a retrospective payment system

Question 27

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.

A formulary lists the drugs and treatment protocols that are considered to be the preferred therapy for a given managed population. The Fairfax Health Plan uses the type of formulary which covers drugs that are on its preferred list as well as drugs that are not on its preferred list. This information indicates that Fairfax uses the (closed / open) formulary method. In using the formulary approach to pharmacy benefits management, Fairfax most likely experiences (higher / lower) costs for its members’ prescription drugs than it would if it did not use a formulary.

Options:

A.

closed / higher

B.

closed / lower

C.

open / higher

D.

open / lower

Question 28

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. A credentials verification organization (CVO) can be certified to verify certain pertinent credentialing information, including

Options:

A.

Liability claims histories of prospective providers

B.

Hospital privileges of prospective providers

C.

Malpractice insurance on prospective providers

D.

All of the above

Question 29

Four types of APCs are ancillary APCs, medical APCs, significant procedure APCs, and surgical APCs. An example of a type of APC known as

Options:

A.

An ancillary APC is a biopsy

B.

Amedical APC is radiation therapy

C.

Asignificant procedure APC is a computerized tomography (CT) scan

D.

Asurgical APC is an emergency department visit for cardiovascular disease

Question 30

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.

One statement that can correctly be made about Gardenia’s two-level POS product is that

Options:

A.

members who self-refer without first seeing their PCPs will receive no benefits

B.

both Gardenia and the PCPs stand to benefit if the non-provider panels are kept relatively narrow

C.

members will pay higher coinsurance or copayments if they first see their PCPs each time

D.

the plan offers no financial incentives to members to choose an in-network specialist over a non-network specialist

Demo: 30 questions
Total 202 questions