AHIP AHM-540 Online Practice Questions and Exam Preparation

AHIP AHM-540 Online Questions & Answers

• Question 71:

  Federal laws, such as the Employee Retirement Income Security Act (ERISA), the Balanced Budget Act (BBA) of 1997, and the Health Insurance Portability and Accountability Act (HIPAA), have affected medical management activities by health plans. Consider the following provisions of federal regulations:

  Provision 1--Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered treatment and does not allow health plan members to obtain compensatory or punitive damages

  Provision 2--Establishes electronic data security standards, which define the security measures that healthcare organizations must take to protect the confidentiality of electronically stored and transmitted patient information From the answer choices below, select the response that correctly identifies the federal laws that include Provision 1 and Provision 2, respectively.

  A. Provision 1- ERISA Provision 2- HIPAA
  B. Provision 1- HIPAA Provision 2- ERISA
  C. Provision 1- BBA of 1997 Provision 2- HIPAA
  D. Provision 1- ERISA Provision 2- BBA of 1997
  A. Provision 1- ERISA Provision 2- HIPAA

• Question 72:

  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
  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

• Question 73:

  The following statement(s) can correctly be made about performance measurement systems:

  1.The most difficult purpose for a performance measurement system to address is to measure changes in outcomes caused by modifications in administrative or clinical treatment processes

  2.A

  health plan needs different performance measurement systems to evaluate its administrative services and the clinical performance of its providers

  A. Both 1 and 2
  B. 1 only
  C. 2 only
  D. Neither 1 nor 2
  C. 2 only

• Question 74:

  CMS has developed two prototype programs--Programs of All-inclusive Care for the Elderly (PACE) and the Social Health Maintenance Organization (SHMO) demonstration project--to deliver healthcare services to Medicare beneficiaries. From the answer choices below, select the response that correctly identifies the features of these programs.

  A. PACE-annual limits on benefits for nursing home and community-based care SHMO-no limits on long-term care benefits
  B. PACE-provide long-term care only SHMO-provide acute and long-term care
  C. PACE-enrollees must be age 65 or older SHMO-enrollees must be age 55 or older
  D. PACE-enrollment open to nursing home certifiable Medicare beneficiaries only SHMO- enrollment open to all Medicare beneficiaries
  D. PACE-enrollment open to nursing home certifiable Medicare beneficiaries only SHMO- enrollment open to all Medicare beneficiaries

• Question 75:

  The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral

  healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through 1.The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

  2.The National Committee for Quality Assurance (NCQA)

  3.The American Accreditation HealthCare Commission/URAC (URAC)

  A. All of the above
  B. 1 and 2 only
  C. 2 and 3 only
  D. 1 only
  B. 1 and 2 only

• Question 76:

  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
  A. utilization review (UR)

• Question 77:

  The BBA of 1997 allows states to provide Medicaid benefits to children through the State Children's Health Insurance Program (SCHIP). Under the terms of the BBA, states can implement SCHIP as 1.Part of their existing Medicaid programs 2.Separate commercial insurance programs

  A. Both 1 and 2
  B. 1 only
  C. 2 only
  D. Neither 1 nor 2
  A. Both 1 and 2

• Question 78:

  The Strathmore Health Plan uses clinical pathways to manage its acute care services. In order to reduce the risk of financial liability associated with the use of clinical pathways, Strathmore and its network hospitals should

  A. base pathways on relevant evidence reported in medical literature
  B. restrict each pathway to a single medical condition
  C. use pathways to establish a new standard of care
  D. allow providers to use only those interventions listed in the pathways
  A. base pathways on relevant evidence reported in medical literature

• Question 79:

  The following statements are about the use of provider profiling for pharmacy benefits. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

  A. Health plans typically use provider profiles to improve the quality of care associated with the use of prescription drugs.
  B. Provider profiles identify prescribing patterns that fall outside normal ranges.
  C. Health plans can motivate providers to change their prescribing patterns by sharing profile information with plan members and the general public.
  D. Provider profiles are effective in modifying individual prescribing patterns, but they have little effect on group prescribing patterns.
  D. Provider profiles are effective in modifying individual prescribing patterns, but they have little effect on group prescribing patterns.

• Question 80:

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