AHIP AHIP Certifications AHM-250 Questions & Answers

• Question 321:

  Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.

  A. The Serenity Healthcare Organization requires a plan member or the provider in charge of the member's care to obtain authorization for inpatient care before the member is admitted to the hospital.

  B. UR nurses employed by the Friendship Health Plan monitor length of stay to identify factors that might contribute to unnecessary hospital days.

  C. The Optimum Health Group evaluates the medical necessity and appropriateness of proposed services and intervenes, if necessary, to redirect care to a more appropriate care setting.

  D. The Axis Medical Group examines provider practice patterns to identify areas in which services are being underused, overused, or misused and designs strategies to prevent inappropriate utilization in the future.

  Correct Answer: D

• Question 322:

  As part of its utilization management (UM) system, the Creole Health Plan uses a process known as case management. The following individuals are members of the Creole Health Plan:

  Jill Novacek, who has a chronic respiratory condition. Abraham Rashad.

  A. Ms. Novacek, Mr. Rashad, and Mr. Devereaux

  B. Ms. Novacek and Mr. Rashad only

  C. Ms. Novacek and Mr. Devereaux only

  D. None of these members

  Correct Answer: A

• Question 323:

  Identify the CORRECT statement(s):

  (A)

  Smaller the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.

  (B)

  Gender of the group's participants has no effect on the likelihood of loss.

  A.

  All of the listed options

  B.

  B and C

  C.

  None of the listed options

  D.

  A and C

  Correct Answer: C

• Question 324:

  Amendments to the HMO act 1973 do not permit federally qualified HMO's to use

  A. Retrospective experience rating

  B. Adjusted community rating

  C. Community rating by class

  D. Community rating

  Correct Answer: A

• Question 325:

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

  A. Staffing ratios

  B. Drive time

  C. Geographic availability

  D. All of the above

  Correct Answer: D

• Question 326:

  In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care.

  A. Such intervention can be based on the results of

  B. Prospective review

  C. Concurrent review

  A. A, B, and C

  B. A and B only

  C. A and C only

  D. B only

  Correct Answer: B

• Question 327:

  Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further investigation of a claim. In an automated claims processing system, these criteria may signal the need for further review when, for example

  A. Encounter reports

  B. Diagnostic codes

  C. Durational ratings

  D. Edits

  Correct Answer: D

• Question 328:

  Historically most HMOs have been

  A. Closed-access HMO

  B. Closed-panel HMO

  C. Open-access HMO

  D. Open-panel HMO

  Correct Answer: B

• Question 329:

  Bill Clinton is a member of Lewinsky's PBM plan which has a three-tier copayment structure. Bill fell ill and his doctor prescribed him AAA, a brand-name drug which was included in the Lewinsky's formulary; BBB, a non-formulary drug; and CCC, a generic dr

  A. CCC, AAA, BBB

  B. BBB, CCC, AAA

  C. BBB, AAA, CCC

  D. CCC, BBB, AAA

  Correct Answer: A

• Question 330:

  In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known

  A. dual choice

  B. cost shifting

  C. accreditation

  D. defensive medicine

  Correct Answer: B