AHIP AHIP Certification AHM-540 Questions & Answers

• Question 21:

  The Fairview Health Plan uses a dual database approach to integrate information needed for its disease management program. This information indicates that Fairview uses an information management system that

  A. combines all existing information from all data sources into a single comprehensive system

  B. connects multiple databases with a central interface engine that acts as an information clearinghouse

  C. provides an outside vendor with pertinent data that the vendor compiles into an integrated database

  D. creates a separate database that pulls pertinent information from the health plan's claims database, formats the information for easy analysis, and stores it in the separate database

  Correct Answer: D

• Question 22:

  The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

  To manage the delivery of healthcare services to their members, health plans use clinical practice parameters. ___________________ is the type of clinical practice parameter that a health plan uses to make coverage decisions concerning medical necessity and appropriateness.

  A. A clinical practice guideline (CPG)

  B. Medical policy

  C. Benefits administration policy

  D. A standard of care

  Correct Answer: B

• Question 23:

  Since its inception, Medicare has undergone a number of changes because of legal and regulatory action. One result of the Balanced Budget Act (BBA) of 1997 has been to

  A. expand Medicare benefits by mandating coverage for certain preventive services

  B. reduce the number of organizations that can deliver covered services

  C. encourage growth of managed Medicare programs in all markets

  D. increase the number of "zero premium" plans available to Medicare beneficiaries

  Correct Answer: A

• Question 24:

  The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

  Definitions of quality healthcare vary; however, four dimensions are essential to quality healthcare services. ________________ is the quality dimension indicating that services result in the best care for a given cost or the lowest cost for a given level of care.

  A. Accessibility

  B. Effectiveness

  C. Acceptability

  D. Efficiency

  Correct Answer: D

• Question 25:

  Maxwell Midler's health plan operates a drug formulary that includes a typical three-tier copayment structure with required copayments of $5, $10, and $25. Mr. Midler recently filled a prescription for a $75 drug that was not included in the formulary. According to the plan's formulary copayment structure, the amount that Mr. Midler was required to pay for his prescription was

  A. $5

  B. $10

  C. $25

  D. $75

  Correct Answer: C

• Question 26:

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

  A primary distinction between skilled care and subacute care relates to the extent and medical complexity of the patient's needs. Generally, subacute care patients require (more / fewer) services from physicians and nurses and (more / less) extensive rehabilitation services than do skilled care patients.

  A. more / more

  B. more / less

  C. fewer / more

  D. fewer / less

  Correct Answer: A

• Question 27:

  A health plan's preventive care initiatives may be classified into three main categories: primary prevention, secondary prevention, and tertiary prevention. Secondary prevention refers to activities designed to

  A. develop an appropriate treatment strategy for patients whose conditions require extensive, complex healthcare

  B. educate and motivate members to prevent illness through their lifestyle choices

  C. prevent the occurrence of illness or injury

  D. detect a medical condition in its early stages and prevent or at least delay disease progression and complications

  Correct Answer: D

• Question 28:

  In order to be effective, a clinical pathway must improve quality and decrease costs.

  A. True

  B. False

  Correct Answer: B

• Question 29:

  The Quality Assessment Performance Improvement (QAPI) is a quality initiative designed to strengthen health plans' efforts to protect and improve the health and satisfaction of Medicare and Medicaid health plan enrollees. The Centers for Medicare and Medicaid Services (CMS) requires compliance with QAPI from

  A. both Medicare+Choice plans and Medicaid health plans

  B. Medicare+Choice plans only

  C. Medicaid health plans only

  D. neither Medicare+Choice plans nor Medicaid health plans

  Correct Answer: B

• Question 30:

  For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.

  In most commercial health plans, the case management process is directed by a case manager whose responsibilities typically include

  A. focusing on a disabled member's vocational rehabilitation and training

  B. approving all care decisions for patients under case management

  C. reducing the fragmentation of care that often results when individuals obtain services from several different providers

  D. all of the above

  Correct Answer: C