AHIP AHIP Certifications AHM-510 Questions & Answers

• Question 51:

  Several states have adopted clinical practice guidelines for treating workers' compensation injuries. Clinical practice guidelines can best be described as

  A. Fee schedules that specify the maximum amount providers may charge for treating workers' compensation patients

  B. A utilization management and quality management mechanism designed to aid providers in making decisions about the most appropriate course of treatment for a specific case

  C. Detailed plans of medical treatment designed to facilitate a patient's return to the workplace

  D. Payment practices that might technically violate the provisions of the anti-kickback statute but that will not be considered illegal and for which providers and health plans will not be subject to penalties

  Correct Answer: B

• Question 52:

  The following situations illustrate per se violations of federal antitrust laws:

  Situation A - Two groups of providers agreed among themselves that each provider will do business with health plans only on a fee-for-service basis.

  Situation B - In order to avoid competing with each other, two independent, competing physician-hospital organizations (PHOs) divide the geographic areas in which they will market their services.

  From the following answer choices, select the response that correctly identifies the types of per se violations illustrated by these situations.

  A. Situation A: price fixing; Situation B: horizontal division of markets

  B. Situation A: price fixing; Situation B: tying arrangement

  C. Situation A: horizontal group boycott; Situation B: horizontal division of markets

  D. Situation A: horizontal group boycott; Situation B: tying arrangement

  Correct Answer: A

• Question 53:

  Any willing provider laws have their share of proponents and opponents. Arguments commonly made in opposition to any willing provider laws include

  A. That such laws reduce the number of providers in a health plan's network

  B. That such laws limit consumer choice to coverage options that are more costly than network-based plans

  C. That such laws encourage providers to offer discounts in exchange for patient volume

  D. All of the above

  Correct Answer: B

• Question 54:

  One typical difference between a for-profit health plan's board of directors and a not-for- profit health plan's board of directors is that the directors in a for-profit health plan

  A. Can serve on the board for a period of no more than ten years, whereas the terms of service for a not-for-profit board's directors are usually unlimited by the director's age or by a preset maximum number of years of service

  B. Must participate in raising capital for the health plan, whereas a not-for-profit board's directors are prohibited from participating directly in raising capital for the health plan

  C. Are directly accountable to shareholders, whereas a not-for-profit board's directors are accountable to plan members and the community

  D. Are not compensated for board participation, whereas a not-for-profit board's directors are compensated for board participation

  Correct Answer: C

• Question 55:

  The Department of Health and Human Services (HHS) has delegated its responsibility for development and oversight of regulations under the Health Insurance Portability and Accountability Act (HIPAA) to an office within the Centers for Medicaid and Medicare Services (CMS). The CMS office that is responsible for enforcing the federal requirements of HIPAA is the

  A. Center for Health Plans and Providers (CHPPs)

  B. Center for Medicaid and State Operations

  C. Center for Beneficiary Services

  D. Center for Managed Care

  Correct Answer: B

• Question 56:

  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

• Question 57:

  The government uses various tools within the realm of two broad categories of public policy-allocative policies and regulatory policies. In the context of public policy, laws that fall into the category of allocative policy include

  A. The Balanced Budget Act (BBA) of 1997

  B. The Health Insurance Portability and Accountability Act (HIPAA) of 1996

  C. Laws affecting health plan quality oversight

  D. Laws specifying procedures for health plan handling of consumer appeals and grievances

  Correct Answer: A

• Question 58:

  Determine whether the following statement is true or false:

  Although most-favored-nation (MFN) clauses in contracts between health plans and healthcare providers are not per se illegal, they should be reviewed under the rule of reason analysis for antitrust purposes.

  A. True, because the Federal Trade Commission (FTC) ruled that MFN clauses are not per se illegal and the FTC encourages health plans to include them in provider contracts.

  B. True, because although MFN clauses are not per se illegal, they violate antitrust laws if they have a predatory purpose and an anticompetitive effect.

  C. False, because MFN clauses involve decisions by providers concerning the level of fees to charge, and thus they are per se illegal.

  D. False, because MFN clauses are not per se illegal, and thus they are exempt from antitrust laws and regulation by the FTC.

  Correct Answer: B

• Question 59:

  Health plans typically divide their costs into medical and administrative expenses. Examples of medical expenses are.

  A. Equipment costs

  B. Salaries and benefits for executives and for all functional areas

  C. Sales and marketing costs

  D. Payments to providers for the delivery of healthcare

  Correct Answer: D

• Question 60:

  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 provider network. 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.

  With respect to the type of change that constitutes a material change under the HMO Model Act's disclosure requirements, the termination of one healthcare provider from Greenpath's provider network

  A. Always qualifies as a material change in the plan, and Greenpath must report the change to all plan enrollees

  B. Always qualifies as a material change in the plan, and Greenpath must report the change to only those plan enrollees who have received care from the terminated provider

  C. Qualifies as a material change in the plan only if the provider is a primary care provider, and in such a case Greenpath must report the change to all plan enrollees

  D. Qualifies as a material change in the plan only if the provider is a primary care provider, and in such a case Greenpath must report the change to only those plan enrollees who receive primary care from the terminated provider

  Correct Answer: D