AHIP AHIP Certification AHM-510 Questions & Answers

• Question 21:

  SoundCare Health Services, an MCO, 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 detecting violations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.

  By definition, the activity that SoundCare conducted when it examined its strengths, weaknesses, and capabilities is known as

  A. An environmental analysis

  B. An internal assessment

  C. An environmental forecast

  D. A community analysis

  Correct Answer: B

• Question 22:

  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.

  In the case of Pacificare of Oklahoma, Inc. v. Burrage, the U.S. Court of Appeals for the Tenth Circuit considered whether ERISA preempts medical malpractice claims against health plans based on certain liability theories. In this case, the Tenth Circuit court held that ERISA (should / should not) preempt a liability claim against an HMO for the malpractice of one of its primary care physicians, and therefore the HMO was subject to a claim of (subordinated / vicarious) liability.

  A. Should / subordinated

  B. Should / vicarious

  C. Should not / subordinated

  D. Should not / vicarious

  Correct Answer: D

• Question 23:

  Directors on a health plan's board must demonstrate their compliance with three duties in all their decisions. Directors who exercise their duties in good faith and with the same degree of diligence and skill that an ordinary, reasonable person would be expected to display in the same situation are meeting the duty known as the

  A. Duty of loyalty

  B. Duty to supervise

  C. Duty of care

  D. Trustee duty

  Correct Answer: C

• Question 24:

  The Balanced Budget Act (BBA) of 1997 created the Medicare+Choice plan. One provision of the BBA under Medicare+Choice is that the BBA A. Requires health plans to qualify as either a competitive medical plan (CMP) or a federally qualified HMO in order to participate in the Medicare program

  B. Eliminates funding for demonstration projects such as the Medicare Enrollment Demonstration Project

  C. Narrows the geographic variations in payments to Medicare health plans by lowering the growth rate of payments in high-payment counties and raising the rates in low-payment counties

  D. Increases Graduate Medical Education (GME) payments to hospitals for the training and cost of educating and training residents

  Correct Answer: C

• Question 25:

  TRICARE, a military healthcare program, offers eligible beneficiaries three options for healthcare services: TRICARE Prime, TRICARE Extra, and TRICARE Standard. With respect to plan features, both an annual deductible and claims filing requirements must be met, regardless of whether care is delivered by network providers, under

  A. TRICARE Prime and TRICARE Extra only

  B. TRICARE Extra and TRICARE Standard only

  C. TRICARE Standard only

  D. None of these healthcare options

  Correct Answer: C

• Question 26:

  The Opal Health Plan complies with all of the provisions of the Newborns' and Mothers' Health Protection Act of 1996 (NMHPA). Samantha Hill and Debra Chao are Opal enrollees. Ms. Hill was hospitalized for a cesarean birth, and Ms. Chao was hospitalized for a normal delivery. From the following answer choices, select the response that indicates the minimum hospital stay for which Opal, under NMHPA, must provide benefits for Ms. Hill and Ms. Chao.

  A. Ms. Hill: 72 hours; Ms. Chao: 24 hours

  B. Ms. Hill: 72 hours; Ms. Chao: 48 hours

  C. Ms. Hill: 96 hours; Ms. Chao: 24 hours

  D. Ms. Hill: 96 hours; Ms. Chao: 48 hours

  Correct Answer: D

• Question 27:

  The Nonprofit Institutions Act allows the Neighbor Hospital, a not-for-profit hospital, to purchase at a discount drugs for its 'own use'. Consider whether the following sales of drugs were not for Neighbor's own use and therefore were subject to antitrust enforcement:

  Elijah Jamison, a former patient of Neighbor, renewed a prescription that was originally dispensed when he was discharged from Neighbor.

  Neighbor filled a prescription for Camille Raynaud, who has no connection to Neighbor other than that her prescribing physician is located in a nearby physician's office building.

  Neighbor filled a prescription for Nigel Dixon, who is a friend of a Neighbor medical staff member.

  With respect to the United States Supreme Court's definition of 'own use,' the drug sales that were not for Neighbor's own use were the sales that Neighbor made to

  A. Mr. Jamison, Ms. Raynaud, and Mr. Dixon

  B. Mr. Jamison and Ms. Raynaud only

  C. Mr. Dixon only

  D. None of these individuals

  Correct Answer: A

• Question 28:

  Brighton Health Systems, Inc., a health plan, wants to modify its advertising and marketing materials to avoid liability risk under the principle of ostensible agency. One step that Brighton can take to reduce the likelihood of being liable for provider negligence under the theory of ostensible agency is to

  A. Guarantee the quality of medical care provided to Brighton members

  B. Use advertising materials which state that Brighton itself provides healthcare

  C. Add disclaimers to advertising materials indicating that only physicians and not Brighton make medical decisions

  D. Use advertising materials to characterize Brighton's role as providing physicians, hospitals, and other healthcare professionals rather than arranging for healthcare.

  Correct Answer: C

• Question 29:

  The Tidewater Life and Health Insurance Company is owned by its policy owners, who are entitled to certain rights as owners of the company, and it issues both participating and nonparticipating insurance policies. Tidewater is considering converting to the type of company that is owned by individuals who purchase shares of the company's stock. Tidewater is incorporated under the laws of Illinois, but it conducts business in the Canadian provinces of Ontario and Manitoba.

  Tidewater established the Diversified Corporation, which then acquired various subsidiary firms that produce unrelated products and services. Tidewater remains an independent corporation and continues to own Diversified and the subsidiaries. In order to create and maintain a common vision and goals among the subsidiaries, the management of Diversified makes decisions about strategic planning and budgeting for each of the businesses.

  In order to become the type of company that is owned by people who purchase shares of the company's stock, Tidewater must undergo a process known as

  A. management buy-out

  B. piercing the corporate veil

  C. demutualization

  D. mutualization

  Correct Answer: C

• Question 30:

  The following statements are about the Federal Employees Health Benefits Program (FEHBP), which is administered by the Office of Personnel Management (OPM). Three of the statements are true and one statement is false. Select the answer choice that contains the FALSE statement.

  A. For every plan in the FEHBP, OPM annually determines the lowest premium that is actuarially sound and then negotiates with each plan to establish that premium rate.

  B. Once a health plan has submitted its rate proposals for a contract year to the OPM, it cannot adjust its premium rate for any reason.

  C. To cover its administrative costs, OPM sets aside 1% of all FEHBP premiums.

  D. Each spring, OPM sends all plan providers its call letter, a document that specifies the kinds of benefits that must be available to plan participants and cost goals and procedural changes that the plans need to adopt.

  Correct Answer: A