AHIP AHIP Certification AHM-510 Questions & Answers

• Question 11:

  SoundCare Health Services, a health plan, recently conducted a situation analysis. One step in this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activity provided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detectingviolations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.

  With respect to the Federal Sentencing Guidelines, actions that SoundCare should take in developing its compliance program include

  A. Creating a system through which employees and other agents can report suspected misconduct without fear of retribution

  B. Holding management accountable for the misconduct of their subordinates

  C. Assigning a high-level member of management to the position of compliance coordinator or administrator

  D. All of the above

  Correct Answer: D

• Question 12:

  State X issued a nonresident license to Tamara Pensky, a sales representative of the Verity Health Plan. In doing so, State X imposed a countersignature requirement, which requires that

  A. An officer of Verity sign a written statement which indicates that Verity appoints Ms. Pensky as an agent who is authorized to market Verity's products

  B. An officer of Verity sign a written statement which certifies that Verity has investigated Ms. Pensky's qualifications and background and believes she is trustworthy and competent

  C. Applications solicited by Ms. Pensky must be signed by an individual who holds a resident License

  D. Applications solicited by Ms. Pensky must be signed by an officer of Verity

  Correct Answer: C

• Question 13:

  The following statements are about various provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Three of the statements are true and one statement is false. Select the answer choice that contains the FALSE statement.

  A. HIPAA permits group health plans that offer coverage through an HMO to impose affiliation periods during which no benefits or services are provided to a plan member.

  B. HIPAA created a new category of federal healthcare crimes, called federal healthcare offenses that apply to private healthcare plans as well as to federally funded healthcare programs.

  C. One effect of Section 231(h) of HIPAA, which amended the Social Security Act, has been to permit health plans with Medicare contracts to provide enrollees with value-added services such as discounted memberships to health clubs.

  D. HIPAA provides that any fines and penalties recovered through regulatory proceedings to enforce the federal fraud and abuse statutes will be turned over to enforcement agencies to conduct additional investigations.

  Correct Answer: C

• Question 14:

  There are several exceptions to the Ethics in Patient Referrals Act and its amendments (the Stark laws), which prohibit a physician from referring Medicare or Medicaid patients for certain designated services or supplies provided by entities in which the physician has a financial interest. Consider whether the situations described below qualify as exceptions to the Stark laws:

  Situation A: Dr. Wong is a physician in the Marvel Health Plan's provider network and has a financial relationship with Marvel arising from the health plan's compensation for his services. Marvel is not a prepaid health plan.

  Situation B: Dr. Ryder is a physician in the provider network of the Glen Health Plan, which is not a prepaid health plan. In situations of medical necessity, Dr. Ryder refers Glen patients to a physical therapy clinic that leases office space from him.

  Situation C: Dr. Yost has a compensation arrangement with a health plan for providing health services under the Medicare+Choice program.

  An arrangement that is exempt from the Stark laws is described in

  A. All of these situations

  B. Situations A and C only

  C. Situation B only

  D. Situation C only

  Correct Answer: D

• Question 15:

  Certificate of need (CON) laws apply to health plans in a variety of ways, depending upon the state. By definition, CON laws are laws that are designed to

  A. Regulate the construction, renovation, and acquisition of healthcare facilities as well as the purchase of major medical equipment in a geographical area

  B. Protect commerce from unlawful restraint of trade, price discrimination, price fixing, reduced competition, and monopolies

  C. Determine benefit payments when a person is covered by more than one plan, such as two group health plans

  D. License and regulate health plans that wish to establish and operate an HMO

  Correct Answer: A

• Question 16:

  There are several approaches to the interagency division of responsibility for managed care entity (MCE) oversight. In State M, the state Medicaid agency, the state department of health, and the state insurance department are all responsible for ensuring that quality improvement programs are in place among the same group of MCEs and that these programs meet each agency's rules and regulations for such programs. This information indicates that State M uses the approach known as the

  A. Parallel model

  B. Shared model

  C. Concurrent model

  D. PACE model

  Correct Answer: C

• Question 17:

  Regulatory and legislative bodies are among the important environmental forces in the health plan industry. The following statements are about such regulation and legislation. Select the answer choice that contains the correct statement.

  A. Federal guidelines exist to direct health plans on compliance issues when a health plan encounters conflicting state laws in a given service area.

  B. Administrative rules and regulations do not carry the force of law.

  C. As stakeholders in the health plan industry, federal and state governments exert tremendous influence over a health plan's formation and operations.

  D. In recent years, the number of health plan bills in the state and the federal legislatures has decreased.

  Correct Answer: C

• Question 18:

  In the paragraph below, a statement contains two pairs of terms enclosed in parentheses.

  Determine which term in each pair correctly completes the statement. Then select the answer choice containing the two terms that you have chosen.

  Inflation plays a role in the health plan environment by influencing the prices of healthcare services, supplies, and coverage. During an inflationary period, consumers typically have (more / less) purchasing power because the prices of goods and services increase (more / less) quickly than income.

  A. More / more

  B. More / less

  C. Less / more

  D. Less / less

  Correct Answer: C

• Question 19:

  A federal law that significantly affects health plans is the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In order to comply with HIPAA provisions, issuers offering group health coverage generally must.

  A. Renew group health policies in both small and large group markets, regardless of the health status of any group member

  B. Provide a plan member with a certificate of creditable coverage at the time the member enrolls in the group plan

  C. Both A and B

  D. A only

  E. B only

  F. Neither A nor B

  Correct Answer: B

• Question 20:

  Greenpath Health Services, Inc., an HMO, recently terminated some providers from its network in response to the changing enrollment and geographic needs of the plan. A provision in Greenpath's contracts with its healthcare providers states that Greenpath can terminate the contract at any time, without providing any reason for the termination, by giving the other party a specified period of notice.

  The state in which Greenpath operates has an HMO statute that is patterned on the NAIC HMO Model Act, which requires Greenpath to notify enrollees of any material change in its providernetwork. As required by the HMO Model Act, the state insurance department is conducting an examination of Greenpath's operations. The scope of the on-site examination covers all aspects of Greenpath's market conduct operations, including its compliance with regulatory requirements.

  From the following answer choices, select the response that identifies the type of market conduct examination that is being performed on Greenpath and the frequency with which the HMO Model Act requires state insurance departments to conduct an examination of an HMO's operations.

  A. Type of examination: comprehensive; Required frequency: annually

  B. Type of examination: comprehensive; Required frequency: at least every three years

  C. Type of examination: target; Required frequency: annually

  D. Type of examination: target; Required frequency: at least every three years

  Correct Answer: B