AHIP AHIP Certifications AHM-540 Questions & Answers

• Question 131:

  Private employers are key purchasers of health plan services. The following statement(s) can correctly be made about employer expectations about the quality and cost- effectiveness of healthcare services:

  1.

  For both health maintenance organizations (HMOs) and non-HMO plans, employers typically have access to accreditation results and performance measurement reports to help them evaluate the quality of healthcare and service

  2.

  Because of employers' concern about the quality and costs of healthcare services available through health plans, direct contracting has become a dominant model among employers who sponsor health benefit programs for their employees

  A. Both 1 and 2

  B. 1 only

  C. 2 only

  D. Neither 1 nor 2

  Correct Answer: D

• Question 132:

  The case management program director at the Nova Health Plan calculated the program's ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:

  Administrative costs for case management ..........$40,000 Actual medical care expenses for patients under case management ..........$680,000 Projected medical care expenses for the same patients without case management ..........$900,000 This information indicates that, for the previous quarter, Nova's ratio of medical expense savings to case

  management administrative costs was

  A. 0.71/1

  B. 0.80/1

  C. 5.50/1

  D. 1.25/1

  Correct Answer: C

• Question 133:

  Determine whether the following statement is true or false:

  Immunization programs are a direct means of reducing health plan members' needs for healthcare services and are typically cost-effective.

  A. True

  B. False

  Correct Answer: A

• Question 134:

  Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.

  The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.

  Greenhouse's prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).

  A. open / mandatory

  B. open / voluntary

  C. closed / mandatory

  D. closed / voluntary

  Correct Answer: C

• Question 135:

  Occasionally, employers combine workers' compensation, group healthcare, and disability programs into an integrated product known as 24-hour coverage. One true statement about 24-hour coverage is that it typically

  A. increases administrative costs

  B. requires plans to maintain separate databases of patient care information

  C. exempts plans from complying with state workers' compensation regulations

  D. allows plans to apply disability management and return-to-work techniques to nonoccupational conditions

  Correct Answer: D

• Question 136:

  By definition, the development and implementation of parameters for the delivery of healthcare services to a health plan's members is known as

  A. utilization management (UM)

  B. quality management (QM)

  C. care management

  D. clinical practice management

  Correct Answer: D

• Question 137:

  Acute care refers to healthcare services for medical problems that

  A. are expected to continue for a minimum of 30 days

  B. are typically treated in a provider's office or outpatient facility

  C. require prompt, intensive treatment by healthcare providers

  D. require low utilization of resources

  Correct Answer: C

• Question 138:

  One difference between outcomes research and clinical research is that outcomes research

  A. provides an absolute measure of treatment results, whereas clinical research provides a relative measure of results

  B. focuses on treatment effectiveness, whereas clinical research focuses on treatment efficacy

  C. examines diseases and treatments in isolation, whereas clinical research considers the effects of changes in health status and quality of life

  D. gathers outcomes data from controlled clinical trials, whereas clinical research collects and analyzes clinical, financial, and administrative data

  Correct Answer: B

• Question 139:

  The Midwest Health Plan delegated utilization review (UR) activities to the Tri-City Utilization Review Organization. After Tri-City improperly recommended denial of payment for services to a Midwest plan member, the plan member filed suit. The court ruled that Midwest was responsible for Tri-City's actions because of the relationship between Midwest and Tri-City. This situation is an illustration of a legal concept known as

  A. vicarious liability

  B. fraud

  C. a tying arrangement

  D. subdelegation

  Correct Answer: A

• Question 140:

  The Medicaid population can be divided into subgroups based on their relative size and the costs of providing benefits. From the answer choices below, select the response that correctly identifies the subgroups that represent the largest percentages of the total Medicaid population and of total Medicaid expenditures. Largest % of Medicaid Population- Largest % of Medicaid Expenditures-

  A. Largest % of Medicaid Population-dual eligibles Largest % of Medicaid Expenditures- children and low-income adults

  B. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for MedicareLargest % of Medicaid Expenditures-dual eligibles

  C. Largest % of Medicaid Population-children and low-income adults Largest % of Medicaid Expenditures-chronically ill or disabled individuals not eligible for Medicare

  D. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for Medicare Largest % of Medicaid Expenditures-children and low-income adults

  Correct Answer: C