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AHIP AHM-540 Medical Management Exam Practice Test

Demo: 24 questions
Total 163 questions

Medical Management Questions and Answers

Question 1

Medicare beneficiaries can obtain healthcare benefits through fee-for-service (FFS) Medicare programs, Medicare medical savings account (MSA) plans, Medigap insurance, or coordinated care plans (CCPs). Unlike other coverage options, CCPs

Options:

A.

provide only those benefits covered by Medicare Part A and Part B

B.

are not subject to federal or state regulation

C.

place primary care at the center of the delivery system

D.

are structured as indemnity plans

Question 2

Readiness is an important consideration for the development of health promotion programs. Readiness refers to

Options:

A.

the availability of previously established health promotion programs to an health plan’s members through employers, providers, or community service agencies

B.

the appropriateness of a program’s educational approach, given the language, literacy level, and cultural sensitivities of the target population

C.

a member’s level of knowledge about existing health risks and problems and the member’s ability and willingness to adopt new health-related behaviors

D.

a member’s access to information technology, such as a video cassette recorder, a computer, or the Internet

Question 3

The Hall Health Plan gathered objective clinical information about the recommended uses and dosages of angiotensin-converting enzyme (ACE) inhibitors and presented the information to network providers to illustrate the appropriate use of these frequently prescribed and expensive drugs. This information indicates that Hall most likely educated its network providers through the use of

Options:

A.

detailing

B.

cognitive services

C.

counter detailing

D.

drug efficacy study implementation (DESI)

Question 4

This agency oversees the Federal Employee Health Benefits Program (FEHBP).

Options:

A.

Health Resources and Services Administration (HRSA)

B.

Office of Personnel Management (OPM)

C.

Department of Health and Human Services (HHS)

D.

Department of Justice (DOJ)

Question 5

Administrative action plans are used when performance problems or opportunities are related to the way the organization itself operates. The following statement(s) can correctly be made about administrative action plans:

1. Administrative action plans allow health plans to coordinate management activities

2. One function of administrative action plans is to integrate service across all levels of the organization

3. Administrative action plans are designed to improve outcomes by helping plan members assume responsibility for their own health

Options:

A.

All of the above

B.

1 and 2 only

C.

1 and 3 only

D.

2 and 3 only

Question 6

Health plans conduct evaluations on the efficiency and effectiveness of their quality improvement activities. With regard to the effectiveness of quality improvement plans, it is correct to say that

Options:

A.

effectiveness is the relationship between what the organization puts into an improvement plan and what it gets out of the plan

B.

effectiveness is measured by reviewing outcomes to determine the accuracy or appropriateness of the strategy and the adequacy of resources allocated to that strategy

C.

the effectiveness of an action plan is typically measured with a concurrent evaluation

D.

an evaluation of plan effectiveness produces one of two results: the plan either (a) achieved the desired outcomes or (b) did not achieve the desired outcomes and is unlikely to do so under current conditions

Question 7

The paragraph below contains two pairs of terms enclosed in parentheses. Select the term in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.

Under a delegation arrangement, the (delegate / delegator) is responsible for performing the delegated function according to established standards, and the (delegate / delegator) is ultimately accountable for any deficiencies in the performance of the function.

Options:

A.

delegate / delegate

B.

delegate / delegator

C.

delegator / delegate

D.

delegator / delegator

Question 8

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

Options:

A.

Both 1 and 2

B.

1 only

C.

2 only

D.

Neither 1 nor 2

Question 9

To measure performance for quality management, health plans collect and analyze three types of data: financial data, clinical data, and customer satisfaction data. The following statement(s) can correctly be made about the sources of clinical data:

1. Patient surveys are the most widely used source of disease-specific clinical information

2. Outcomes research studies sponsored by academic institutions and professional organizations have limited usefulness for particular health plans or individual providers

3. The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys address both physical and mental health status

Options:

A.

All of the above

B.

1 and 2 only

C.

2 and 3 only

D.

3 only

Question 10

This agency has authority over Programs of All-inclusive Care for the Elderly (PACE) and the State Children’s Health Insurance Program (SCHIP).

Options:

A.

Health Resources and Services Administration (HRSA)

B.

Office of Personnel Management (OPM)

C.

Department of Health and Human Services (HHS)

D.

Department of Justice (DOJ)

Question 11

A health plan's preventive care initiatives may be classified into three main categories: primary prevention, secondary prevention, and tertiary prevention. Secondary prevention refers to activities designed to

Options:

A.

develop an appropriate treatment strategy for patients whose conditions require extensive, complex healthcare

B.

educate and motivate members to prevent illness through their lifestyle choices

C.

prevent the occurrence of illness or injury

D.

detect a medical condition in its early stages and prevent or at least delay disease progression and complications

Question 12

The Riverside Health Plan is considering the following provider compensation options to use in its contracts with several provider groups and hospitals:

1. A discounted fee-for-service (DFFS) payment system

2. A case rate system

3. Capitation

If Riverside wants to use only those compensation methods that encourage the efficient use of resources, then the compensation method(s) that Riverside should consider for its new contracts include

Options:

A.

1, 2, and 3

B.

1 and 2 only

C.

2 and 3 only

D.

3 only

Question 13

The American Accreditation HealthCare Commission/URAC (URAC) has an accreditation program specifically for case management services. From the answer choices below, select the response that correctly identifies the type(s) of case management services addressed by URAC’s standards and the type(s) of organizations to which these standards may be applied.

Options:

A.

Type(s) of Services-on-site services only Type(s) of Organization-health plans only

B.

Type(s) of Services-on-site services only Type(s) of Organization-any organization that performs case management functions

C.

Type(s) of Services-both telephonic and on-site services Type(s) of Organization-health plans only

D.

Type(s) of Services-both telephonic and on-site services Type(s) of Organization-any organization that performs case management functions

Question 14

Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans typically use home healthcare include

1. The period prior to a hospital admission

2. The period following discharge from a hospital

Options:

A.

Both 1 and 2

B.

1 only

C.

2 only

D.

Neither 1 nor 2

Question 15

The following statements are about the characteristics of a utilization review (UR) program. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

Options:

A.

A primary goal of UR is to address practice variations through the application of uniform standards and guidelines.

B.

UR evaluates whether the services recommended by a member’s provider are covered under the benefit plan.

C.

UR recommends the procedures that providers should perform for plan members.

D.

A health plan’s UR program is usually subject to review and approval by the state insurance and/or health departments.

Question 16

The paragraph below contains two pairs of terms 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.

Health plans use both internal and external standards to assess the quality of the services that they provide. (Internal / External) standards are based on information such as published industry-wide averages or best practices of recognized industry leaders. Health plans primarily rely on (internal / external) standards to evaluate healthcare services.

Options:

A.

Internal / internal

B.

Internal / external

C.

External / internal

D.

External / external

Question 17

This agency oversees fraud and abuse matters as they relate to medical management.

Options:

A.

Health Resources and Services Administration (HRSA)

B.

Office of Personnel Management (OPM)

C.

Department of Health and Human Services (HHS)

D.

Department of Justice (DOJ)

Question 18

The following statements are about the use of provider profiling for pharmacy benefits. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

Options:

A.

Health plans typically use provider profiles to improve the quality of care associated with the use of prescription drugs.

B.

Provider profiles identify prescribing patterns that fall outside normal ranges.

C.

Health plans can motivate providers to change their prescribing patterns by sharing profile information with plan members and the general public.

D.

Provider profiles are effective in modifying individual prescribing patterns, but they have little effect on group prescribing patterns.

Question 19

For this question, if answer choices (a) through (c) are all correct, select answer choice (d). Otherwise, select the one correct answer choice.

Well-crafted clinical practice guidelines (CPGs) can benefit healthcare delivery processes and outcomes by

Options:

A.

providing a framework for care while also allowing for patient-specific variations, based on physician judgment

B.

serving as a basis for evaluating whether providers are practicing in accordance with accepted standards

C.

focusing on the prevention or early detection of a particular condition

D.

all of the above

Question 20

Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide should Mr. Farrell become incapacitated.

The document that Mr. Farrell is using to communicate his end-of-life healthcare wishes to his family is known as a

Options:

A.

medical power of attorney

B.

patient assessment and care plan

C.

living will

D.

healthcare proxy

Question 21

Comorbidity can have a significant impact on the effective implementation of disease management programs. Comorbidity can correctly be defined as the

Options:

A.

degree to which the progression of a disease or condition is understood

B.

prevalence or rate of a sickness or injury within a given population

C.

degree of severity of a particular disease or condition

D.

presence of a chronic condition or added complication other than the condition that requires medical treatment

Question 22

Increased demands for performance information have resulted in the development of various health plan report cards. With respect to most of the report cards currently available, it is correct to say

Options:

A.

that they are focused primarily on health maintenance organization (HMO) plans

B.

that they are based on data collected for the Health Plan Employer Data and Information Set (HEDIS) 3.0

C.

that they are used to rank the performance of various health plans

D.

all of the above

Question 23

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. Sharma’s 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

Options:

A.

specialty referral

B.

primary prevention

C.

urgent care

D.

emergency care

Question 24

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

Options:

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

Demo: 24 questions
Total 163 questions