AHIP AHIP Certification AHM-510 Questions & Answers

• Question 31:

  Arthur Dace, a plan member of the Bloom health plan, tried repeatedly over an extended period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr. Dace informally surveyed other Bloom plan members and found that many people were experiencing similar problems getting an appointment with this particular provider. Mr. Dace threatened to take legal action against Bloom, alleging that the health plan had deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making it difficult for patients to make appointments with Dr. Pyle.

  Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR) method that is quicker and less expensive than litigation. Under this ADR method, both Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who issued a decision that Bloom's utilization management practices in this case did not constitute a form of abuse. The panel's decision is legally binding on both parties.

  Different types of compensation arrangements in managed care plans, from fee-for-service (FFS) arrangements to capitation arrangements, lead to different types of fraud and abuse. From the answer choices below, select the response that identifies the form of abuse in which Bloom is allegedly engaging, according to Mr. Dace's complaint, and whether this form of abuse is more likely to occur in FFS compensation arrangements or in capitation arrangements.

  A. Type of abuse underutilization Type of compensation arrangement FFS arrangement

  B. Type of abuse underutilization Type of compensation arrangement capitation arrangement

  C. Type of abuse overutilization Type of compensation arrangement FFS arrangement

  D. Type of abuse overutilization Type of compensation arrangement capitation arrangement

  Correct Answer: B

• Question 32:

  The Good and Well Pharmacy, a Medicaid provider of outpatient drugs, is subject to the prospective drug utilization review (DUR) mandates of the Omnibus Budget Reconciliation Act of 1990 (OBRA '90). One component of prospective DUR is screening. In this context, when Good and Well is involved in the process of screening, the pharmacy is

  A. Updating a formulary to represent the current clinical judgment of providers and experts in the diagnosis and treatment of disease

  B. Reviewing patient profiles for the purpose of identifying potential problems

  C. Consulting directly with prescribers and patients in the planning of drug therapy

  D. Denying coverage for the off-label use of approved drugs

  Correct Answer: B

• Question 33:

  The Hanford Health Plan has delegated the credentialing of its providers to the Sienna Group, a credential verification organization (CVO). If the contract between Hanford and Sienna complies with all of the National Committee for Quality Assurance (NCQA) guidelines for delegation of credentialing, then this contract

  A. Transfers to Sienna all rights to terminate or suspend individual practitioners or providers in Hanford's provider network

  B. Describes the process by which Hanford evaluates Sienna's performance in credentialing providers

  C. Both A and B

  D. A only

  E. B only

  F. Neither A nor B

  Correct Answer: C

• Question 34:

  In examining accountability in the current managed care environment, one is likely to find that combinations of various models of accountability are in operation. Under one model of accountability, the primary mechanisms for accountability are the mechanisms of the marketplace-failure to meet standards will result in a loss of demand for services. By definition, this model of accountability is called the

  A. Professional model of accountability

  B. Political model of accountability

  C. Due diligence model of accountability

  D. Economic model of accountability

  Correct Answer: D

• Question 35:

  In 1994, the Department of Justice (DOJ) and the Federal Trade Commission (FTC) revised their 1993 healthcare-specific antitrust guidelines to include analytical principles relating to multiprovider networks. Under the new guidelines, the regulatory agencies will use the rule ofreason to analyze joint pricing activities by competitors in physician or multiprovider networks only if

  A. Provider integration under the network is likely to produce significant efficiencies that benefit consumers

  B. The providers in a network share substantial financial risk

  C. The combining of providers into a joint venture enables the providers to offer a new product

  D. All of the above

  Correct Answer: A

• Question 36:

  States may impose nominal deductibles, coinsurance, or copayments on some Medicaid recipients for certain services. Services for which states can require copayments from Medicaid recipients include:

  A. Emergency services

  B. Family planning services

  C. Both A and B

  D. A only

  E. B only

  F. Neither A nor B

  Correct Answer: D

• Question 37:

  Nightingale Health Systems, a health plan, operates in a state that requires health plans to allow enrollees to visit obstetricians and gynecologists without a referral from a primary care provider. This information indicates that Nightingale must comply with a type of mandate known as a:

  A. Direct access law

  B. Scope-of-practice law

  C. Provider contracting mandate

  D. Physician incentive law

  Correct Answer: A

• Question 38:

  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.

  Tidewater's participating policy owners have the right to

  A. Elect the board of directors on the basis of one vote per policy owner

  B. Elect the board of directors on the basis of one vote for each policy a person owns

  C. Participate in developing a corporate mission statement and strategic plans

  D. Receive stock dividends for each policy they own

  Correct Answer: A

• Question 39:

  Third party administrators (TPAs) provide various administrative services to health plans or groups that provide health benefit plans to their employees or members. Many state laws that regulate TPAs are based on the NAIC Third Party Administrator Model Statute. One provision of the TPA Model Law is that it

  A. Prohibits TPAs from performing insurance functions such as underwriting and claims processing

  B. Prohibits TPAs from entering into an agreement under which the amount of the TPA's compensation is based on the amount of premium or charges the TPA collects

  C. Requires TPAs, upon the termination of a TPA agreement with a group, to immediately transfer all its records relating to the group to the new administrator

  D. Requires TPAs to notify the state insurance department immediately following any material change in the TPA's ownership or control

  Correct Answer: D

• Question 40:

  Antitrust laws can affect the formation, merger activities, or acquisition initiatives of a health plan. In the United States, the two federal agencies that have the primary responsibility for enforcing antitrust laws are the

  A. Internal Revenue Service (IRS) and the Department of Justice (DOJ)

  B. Office of Inspector General (OIG) and the Department of Defense (DOD)

  C. Federal Trade Commission (FTC) and the Department of Labor (DOL)

  D. Federal Trade Commission (FTC) and the Department of Justice (DOJ)

  Correct Answer: D