AHIP AHIP Certification AHM-540 Questions & Answers

• Question 1:

  Economically, health plans cannot provide coverage for every drug available from every manufacturer. As a result, purchaser contracts often include provisions specifying that certain drugs or drug types will not be covered. These provisions are referred to as

  A. limitations

  B. exceptions

  C. exclusions

  D. drug edits

  Correct Answer: C

• Question 2:

  The following statement(s) can correctly be made about the use of screening for secondary prevention:

  1.Screening activities may involve specialty care providers as well as primary care providers (PCPs) and the health plan 2.Secondary prevention often results in more utilization of services immediately following screening 3.Screening focuses on members who have not experienced any symptoms of a particular illness

  A. All of the above

  B. 1 and 3 only

  C. 2 and 3 only

  D. 1 only

  Correct Answer: A

• Question 3:

  The Garnet Health Plan uses provider profiling to measure and improve provider performance. Provider profiling most likely allows Garnet to

  A. evaluate all providers without considering differences in risk

  B. focus on specific clinical decisions of Garnet's providers rather than on patterns of care

  C. identify the outliers and high-value providers in its provider network

  D. measure the effectiveness, but not the efficiency, of Garnet's providers

  Correct Answer: C

• Question 4:

  The following statement(s) can correctly be made about the characteristics of peer review: 1.Peer review is applicable to either single episodes of care or to entire programs of care 2.Most peer review is conducted concurrently 3.Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services

  furnished to Medicare and Medicaid recipients enrolled in health plans

  A. All of the above

  B. 1 and 2 only

  C. 1 and 3 only

  D. 2 and 3 only

  Correct Answer: C

• Question 5:

  With respect to the activities of MCO medical directors, it is correct to say that medical directors typically perform all of the following activities EXCEPT

  A. maintaining clinical practices

  B. delivering performance feedback to providers

  C. participating in utilization management (UM) activities

  D. educating other MCO staff about new clinical developments or provider innovations that might impact clinical practice management

  Correct Answer: A

• Question 6:

  Health plans arrange for the delivery of various levels of healthcare, including 1.Emergency care 2.Urgent care 3.Primary care delivered in a provider's office In a ranking of these levels of care according to cost, beginning with the least expensive level of care and

  ending with the most expensive level of care, the correct order would be

  A. 1--2--3

  B. 2--3--1

  C. 3--1--2

  D. 3--2--1

  Correct Answer: D

• Question 7:

  The Glenway Health Plan's pharmacy and therapeutics (PandT) committee conducted pharmacoeconomic research to measure both the clinical outcomes and costs of two new cholesterol-reducing drugs. Results were presented as a ratio showing the cost required to produce a 1 mcg/l decrease in cholesterol levels. The type of pharmacoeconomic research that Glenway conducted in this situation was most likely

  A. cost-effectiveness analysis (CEA)

  B. cost-minimization analysis (CMA)

  C. cost-utility analysis (CUA)

  D. cost of illness analysis (COI)

  Correct Answer: A

• Question 8:

  A health plan's choice of structure measures, process measures, and outcome measures to evaluate performance depends in part on the scientific soundness of the measures. One approach that a health plan can use to enhance scientific soundness is stratification, which refers to the

  A. identification and removal of unusual cases, such as patients with contraindications to a particular treatment, from consideration

  B. statistical adjustment of outcome measures to account for differences in the severity of illness or the presence of other medical conditions

  C. specification of a target population for a procedure and the data collection and analysis methods to be used

  D. elimination of variation within a patient population by dividing the population into groups that are at a similar level of risk

  Correct Answer: D

• Question 9:

  This agency oversees the Federal Employee Health Benefits Program (FEHBP).

  A. Health Resources and Services Administration (HRSA)

  B. Office of Personnel Management (OPM)

  C. Department of Health and Human Services (HHS)

  D. Department of Justice (DOJ)

  Correct Answer: B

• Question 10:

  For this question, if answer choices (1) through (3) are all correct, select answer choice (4). Otherwise, select the one correct answer choice.

  Health plans sometimes delegate selected medical management activities to their providers or other external entities. Activities that are frequently delegated include

  A. utilization review (UR)

  B. quality management (QM)

  C. preventive health services

  D. all of the above

  Correct Answer: A