AHIP AHIP Certification AHM-540 Questions & Answers

• Question 11:

  Among this agency's accreditation programs are accreditation for preferred provider organizations (PPOs), health plan call centers, and case management organizations. This agency classifies its standards as either "shall" standards or "should" standards.

  A. American Accreditation HealthCare Commission/URAC (URAC)

  B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

  C. Community Health Accreditation Program (CHAP)

  D. National Committee for Quality Assurance (NCQA)

  Correct Answer: A

• Question 12:

  To measure performance for quality management, health plans collect and analyze three types of data: financial data, clinical data, and customer satisfaction data. The following statement(s) can correctly be made about the sources of clinical data:

  1.Patient surveys are the most widely used source of disease-specific clinical information

  2.Outcomes research studies sponsored by academic institutions and professional organizations have limited usefulness for particular health plans or individual providers

  3.The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys address both physical and mental health status

  A. All of the above

  B. 1 and 2 only

  C. 2 and 3 only

  D. 3 only

  Correct Answer: C

• Question 13:

  Step-therapy is a form of prior authorization that reserves the use of more expensive medications for cases in which the use of less expensive medications has been unsuccessful. Step-therapy is appropriate for situations in which

  1.A significant percentage of those treated with the initial therapy will require the second therapy

  2.The delay created when a patient moves from one therapy to the next therapy will not cause serious or permanent effects

  A. Both 1 and 2

  B. 1 only

  C. 2 only

  D. Neither 1 nor 2

  Correct Answer: C

• Question 14:

  Readiness is an important consideration for the development of health promotion programs. Readiness refers to

  A. the availability of previously established health promotion programs to an health plan's members through employers, providers, or community service agencies

  B. the appropriateness of a program's educational approach, given the language, literacy level, and cultural sensitivities of the target population

  C. a member's level of knowledge about existing health risks and problems and the member's ability and willingness to adopt new health-related behaviors

  D. a member's access to information technology, such as a video cassette recorder, a computer, or the Internet

  Correct Answer: C

• Question 15:

  Determine whether the following statement is true or false:

  The key to successfully managing the quality and cost-effectiveness of healthcare services for Medicaid enrollees is to merge Medicaid recipients into existing plans.

  A. True

  B. False

  Correct Answer: B

• Question 16:

  Many health plans use clinical pathways to help manage the delivery of acute care services to plan members. One true statement about clinical pathways is that they

  A. determine which healthcare services are medically necessary and appropriate for a particular patient in a particular situation

  B. outline the services that will be delivered, the providers responsible for delivering the services, the timing of delivery, the setting in which services are delivered, and the expected outcomes of the interventions

  C. cover only services delivered in an acute inpatient setting

  D. address medical conditions that affect a small segment of a given population and with which the majority of providers are unfamiliar

  Correct Answer: B

• Question 17:

  Determine whether the following statement is true or false:

  The utilization review (UR) process produces the greatest number of case management referrals.

  A. True

  B. False

  Correct Answer: A

• Question 18:

  Determine whether the following statement is true or false:

  With respect to the size of a managed care organization (MCO) and its medical management operations, it is correct to say that large health plans typically have more integration among activities and less specialization of roles than do small MCOs.

  A. True

  B. False

  Correct Answer: B

• Question 19:

  The case management team at the Hightower Health Plan reviewed the medical records of the following two plan members to determine the type of care each one needs and the most appropriate setting for that care:

  Ira Morton was hospitalized for a severe stroke. Although his medical condition is stable, the stroke left him partially paralyzed and he will require extensive rehabilitation and 24- hour medical care.

  Theresa Finley is recovering from a total hip replacement and is in need of short-term physical therapy and twice-weekly visits from a licensed nurse to check her blood pressure and the healing of her incision.

  From the answer choices below, select the response that correctly identifies the level of care that would be most appropriate for Mr. Morton and Ms. Finley.

  A. Mr. Morton-acute care Ms. Finley-subacute care

  B. Mr. Morton-palliative care Ms. Finley-acute care

  C. Mr. Morton-subacute care Ms. Finley-skilled care

  D. Mr. Morton-skilled care Ms. Finley-palliative care

  Correct Answer: C

• Question 20:

  All states have laws describing the conditions under which pharmacists can substitute a generic drug for a brand-name drug. With respect to these laws, it is correct to say that in every state,

  A. pharmacists must obtain physician approval before substituting generics for brand-name drugs

  B. pharmacists must obtain authorization from the health plan before substituting generics for brand-name drugs

  C. prescribers must obtain authorization from the health plan before prescribing a brand- name drug

  D. prescribers have some mechanism that allows them to prevent pharmacists from substituting generics for brand-name drugs

  Correct Answer: D