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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 Aztec Health Plan has a variety of organizational committees related to quality and utilization management. These committees include the medical advisory committee, the credentialing committee, the utilization management committee, and the quality management committee. Of these committees, the one that most likely is responsible for providing oversight of Aztec's inpatient concurrent review process is the:

Options:

A.

medical advisory committee

B.

credentialing committee

C.

utilization management committee

D.

quality management committee

Question 2

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 3

One true statement about the Medicaid program in the United States is that:

Options:

A.

The federal financial participation (FFP) in a state's Medicaid program ranges from 20% to 40% of the state's total Medicaid costs

B.

Medicaid regulations mandate specific minimum benefits, under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, for all Medicaid recipients younger than age 30

C.

The individual states have responsibility for administering the Medicaid program

D.

Non-disabled adults and children in low-income families account for the majority of direct Medicaid spending

Question 4

The following activities are the responsibility of either the Nova Health Plan's risk management department or its medical management department:

Options:

A.

Protecting Nova's members against harm from medical care

B.

Improving the overall health status of Nova members by coordinating care across individual episodes of care and the different providers who treat the member

C.

Protecting Nova against financial loss associated with the delivery of healthcare

D.

Establishing outreach programs to encourage the use of preventive health services by Nova's members of these activities, the ones that are more likely to be the responsibility of Nova's risk management department rather than its medical management department are activities:

E.

A, B, and C

F.

A, C, and D

G.

A and C

Question 5

The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:

Options:

A.

Must provide Medicare participants with standard HMO benefits, as well as with limited long-term care benefits

B.

Does not need as great a variety of provider types or as complex a reimbursement method as does a traditional HMO

C.

Receives a payment that is based on reasonable costs and reasonable charges

D.

Most likely provides fewer supportive services than does a traditional HMO, because one of Bruin's goals is to minimize the use of community-based care

Question 6

With regard to the compensation of dental care providers in a managed dental care system, it is correct to state that, typically:

Options:

A.

dental PPOs compensate dentists on a capitated basis

B.

group model dental HMOs (DHMOs) compensate general dental practitioners on a salaried basis

C.

independent practice association (IPA)-model dental HMOs (DHMOs) capitate general dental practitioners

D.

staff model dental HMOs (DHMOs) compensate dentists on an FFS basis

Question 7

The Pine Health Plan has incorporated pharmacy benefits management into its operations to form a unified benefit. Potential advantages that Pine can receive from this action include:

Options:

A.

the fact that unified benefits improve the quality of patient care and the value of pharmacy services to Pine's plan members

B.

the fact that control over the formulary and network contracting can give Pine control over patient access to prescription drugs and to pharmacies

C.

the fact that managing pharmacy benefits in-house gives Pine a better chance to meet customer needs by integrating pharmacy services into the plan's total benefits package

D.

all of the above

Question 8

The BBA of 1997 specifies the ways in which a Medicare+Choice plan can establish and use provider networks. A Medicare+Choice plan that operates as a private fee for service (PFFS) plan is allowed to

Options:

A.

limit the size of its network to the number of providers necessary to meet the needs of its enrollees

B.

require providers to accept as payment in full an amount no greater than 115% of the Medicare payment rate

C.

refuse payment to non-network providers who submit claims for Medicare-covered expenses

D.

shift all risk for Medicare-covered services to network providers

Question 9

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 10

Dr. Ahmad Shah and Dr. Shantelle Owen provide primary care services to Medicare+Choice enrollees of health plans under the following physician incentive plans:

Dr. Shah receives $40 per enrollee per month for providing primary care and an additional $10 per enrollee per month if the cost of referral services falls below a specified level

Dr. Owen receives $30 per enrollee per month for providing primary care and an additional $15 per enrollee per month if the cost of referral services falls below a specified level

The use of a physician incentive plan creates substantial risk for

Options:

A.

Both Dr. Shah and Dr. Owen

B.

Dr. Shah only

C.

Dr. Owen only

D.

Neither Dr. Shah nor Dr. Owen

Question 11

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.

Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:

Options:

A.

Dr. Enberg's young patients receive appropriate immunizations at the right ages

B.

Dr. Enberg conforms to standards for prescribing controlled substances

C.

The condition of one of Dr. Enberg's patients improved after the patient received medical treatment from Dr. Enberg

D.

Dr. Enberg's procedures are adequate for ensuring patients' access to medical care

Question 12

One difference between a fee-for-service (FFS) reimbursement arrangement and capitation is that the FFS arrangement:

Options:

A.

Is a prospective payment system, whereas capitation is a retrospective payment system

B.

Has a potential to induce providers to underutilize medical resources, whereas capitation does not have this potential disadvantage

C.

Bases the amount of reimbursement on the actual medical services delivered, whereas reimbursement under capitation is independent of the actual volume and cost of services provided

D.

Is most often used by health plans to reimburse healthcare facilities, whereas capitation is most often used by health plans to reimburse specialty care providers

Question 13

The actual number of providers included in a provider network can be based on staffing ratios. One true statement about staffing ratios is that, typically:

Options:

A.

A small health plan needs fewer physicians per 1,000 than does a large plan.

B.

A closely managed health plan requires fewer providers than does a loosely managed plan.

C.

Physician-to-enrollee ratios can be used directly only by network-within-a-network model HMOs.

D.

Medicare products require fewer providers than do employer-sponsored plans of the same size.

Question 14

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 15

Reimbursement for prescription drugs and services in a third-party prescription drug plan typically follows one of two approaches: a reimbursement approach or a service approach. One true statement about these approaches is that:

Options:

A.

Payments under the reimbursement method typically are not subject to any copayment or deductible requirements

B.

Payments under the reimbursement approach are typically based on a structured reimbursement schedule rather than on usual, customary, and reasonable (UCR) charges

C.

Most major medical plans follow a service approach

D.

Most current health plan prescription drug plans are service plans

Question 16

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

Options:

A.

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

B.

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

C.

typically operate out of their own offices

D.

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

Question 17

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 18

The provider contract that Dr. Huang Kwan has with the Poplar Health Plan includes a typical scope of services provision. The medical service that Dr. Kwan provided to Alice Meyer, a Poplar plan member, is included in the scope of services. The following statement(s) can correctly be made about this particular medical service:

Options:

A.

Dr. Kwan most likely was required to seek authorization from Poplar before performing this particular service.

B.

Dr. Kwan most likely was paid on a FFS basis for providing this service.

C.

Both A and B

D.

A only

E.

B only

F.

Neither A nor B

Question 19

The Omni Health Plan is interested in expanding the specialty services it offers to its plan members and is considering contracting with the following providers of specialty services:

The Apex Company, a managed vision care organization (MVCO)

The Baxter Managed Behavioral Healthcare Organization (MBHO)

The Cheshire Dental Health Maintenance Organization (DHMO)

As part of its credentialing process, Omni would like to verify that each of these providers has met NCQA’s accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for

Options:

A.

Apex and Baxter only

B.

Apex and Cheshire only

C.

Baxter and Cheshire only

D.

Baxter only

Question 20

The following statements are about some of the issues surrounding the contractual responsibilities of health plans. Select the answer choice containing the correct statement.

Options:

A.

Typically, health plans are required to pay completed claims within 10 days of submission.

B.

Health plans typically are prohibited from examining the financial soundness of a self-funded employer plan that relies on the health plan to pay providers for services received by the plan’s members.

C.

Patient delivery is one of the most significant factors that health plans consider when determining whether provider services should be reimbursed on a capitated or fee-for-service (FFS) basis.

D.

Health plans require all providers to agree to an exclusive provider contract.

Question 21

The Holiday Health Plan is preparing to enter a new market. In order to determine the optimal size of its provider panel in the new market, Holiday is conducting a competitive analysis of provider networks of the market’s existing health plans. Consider whether, in conducting its competitive analysis, Holiday should seek answers to the following questions:

Question 1: What are the cost-containment strategies of the health plans with increasing market shares?

Question 2: What are the premium strategies of the health plans with large market shares?

Question 3: What are the characteristics of health plans that are losing market share?

In its competitive analysis, Holiday should most likely obtain answers to questions

Options:

A.

1, 2, and 3

B.

1 and 2 only

C.

1 and 3 only

D.

2 and 3 only

Question 22

The Walton Health Plan uses the fee-for-service pharmaceutical reimbursement approach known as the maximum allowable cost (MAC) method. If Walton’s MAC list specifies a cost of 8 cents per tablet for a particular drug but the participating pharmacy pays 10 cents per tablet for the drug, then Walton will be obligated to reimburse the pharmacy for

Options:

A.

8 cents per tablet, but the pharmacy can bill the subscriber for the remaining 2 cents per tablet

B.

8 cents per tablet, and the pharmacy cannot bill the subscriber for the remaining 2 cents per tablet

C.

10 cents per tablet, but the pharmacy must refund the extra 2 cents per tablet to the subscriber

D.

10 cents per tablet, and the pharmacy is not required to refund the extra 2 cents per tablet to the subscriber

Question 23

The following statement(s) can correctly be made about hospitalists.

1. The hospitalist’s main function is to coordinate diagnostic and treatment activities to ensure that the patient receives appropriate care while in the hospital.

2. The hospitalist’s role clearly supports the health plan concept of disease management.

Options:

A.

Both 1 and 2

B.

1 only

C.

2 only

D.

Neither 1 nor 2

Question 24

The Justice Health Plan is eligible to submit reportable actions against medical practitioners to the National Practitioner Data Bank (NPDB). Justice is considering whether it should report the following actions to the NPDB:

Action 1—A medical malpractice insurer made a malpractice payment on behalf of a dentist in Justice’s network for a complaint that was settled out of court.

Action 2—Justice reprimanded a PCP in its network for failing to follow the health plan’s referral procedures.

Action 3—Justice suspended a physician’s clinical privileges throughout the Justice network because the physician’s conduct adversely affected the welfare of a patient.

Action 4—Justice censured a physician for advertising practices that were not aligned with Justice’s marketing philosophy.

Of these actions, the ones that Justice most likely must report to the NPDB include Actions

Options:

A.

1, 2, and 3 only

B.

1 and 3 only

C.

2 and 4 only

D.

3 and 4 only

Question 25

One type of fee schedule payment system assigns a weighted unit value for each medical procedure or service based on the cost and intensity of that service. Under this system, the unit values for procedural services are generally higher than the unit values for cognitive services. This system is known as a

Options:

A.

Wrap-around payment system

B.

Relative value scale (RVS) payment system

C.

Resource-based relative value scale (RBRVS) system

D.

Capped fee system

Question 26

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

Question 27

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.

The following statement(s) can correctly be made about Gardenia’s establishment of the PPO and the staff model HMO in its new market:

1. When establishing its PPO network, Gardenia most likely initiated outcomes measurement tools and developed collaborative process improvement relationships with providers.

2. To avoid high overhead expenses in the early stages of market evelopment, Gardenia’s HMO most likely contracted with specialists and ancillary providers until the plan’s membership grew to a sufficient level to justify employing these specialists.

Options:

A.

Both 1 and 2

B.

Neither 1 nor 2

C.

1 Only

D.

2 Only

Question 28

During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider’s application. One true statement regarding this process is that the health plan

Options:

A.

has a legal right to access a prospective provider’s confidential medical records at any time

B.

must limit any evaluations of a prospective provider’s office to an assessment of quantitative factors, such as the number of double-booked appointments a physicianaccepts at the end of each day

C.

is prohibited by law from conducting primary verification of such data as a prospective provider’s scope of medical malpractice insurance coverage and federal tax identification number

D.

must complete the credentialing process before a provider signs the network contract or must include in the signed document a provision that the final contract is contingent upon the completion of the credentialing process

Question 29

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.

In most states, a health plan can be held responsible for a provider’s negligent malpractice. This legal concept is known as (vicarious liability / risk sharing). One step that health plans can take to reduce their exposure to malpractice lawsuits is to state in health plan-provider agreements, marketing collateral, and membership literature that the providers are (employees of the health plan / independent contractors).

Options:

A.

Vicarious liability / employees of the health plan

B.

Vicarious liability / independent contractors

C.

Risk sharing / employees of the health plan

D.

Risk sharing / independent contractors

Question 30

The Brice Health Plan submitted to Clarity Health Services a letter of intent indicating Brice’s desire to delegate its demand management function to Clarity. One true statement about this letter of intent is that it

Options:

A.

creates a legally binding relationship between Brice and Clarity

B.

most likely contains a confidentiality clause committing Brice and Clarity to maintain the confidentiality of documents reviewed and exchanged in the process

C.

prohibits Clarity from performing similar delegation activities for other health plans

D.

most likely contains a detailed description of the functions that Brice will delegate to Clarity

Demo: 30 questions
Total 202 questions