Download Network Management.AHM-530.RealExams.2019-03-15.121q.vcex

Vendor: AHIP
Exam Code: AHM-530
Exam Name: Network Management
Date: Mar 15, 2019
File Size: 114 KB

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Demo Questions

Question 1
Dr. Ahmad Shah and Dr. Shantelle Owen provide primary care services to Medicare+Choice enrollees of health plans under the following physician incentive plans:
Dr. Shah receives $40 per enrollee per month for providing primary care and an additional $10 per enrollee per month if the cost of referral services falls below a specified level 
Dr. Owen receives $30 per enrollee per month for providing primary care and an additional $15 per enrollee per month if the cost of referral services falls below a specified level 
The use of a physician incentive plan creates substantial risk for
  1. Both Dr. Shah and Dr. Owen
  2. Dr. Shah only
  3. Dr. Owen only
  4. Neither Dr. Shah nor Dr. Owen
Correct answer: C
Question 2
An increasing number of health plans offer coverage for alternative healthcare services. One such alternative healthcare service is biofeedback. Biofeedback is an approach that
  1. is based on an ancient Chinese system of healing in which needles are inserted into specific sites on the body to relieve pain
  2. treats diseases with tiny doses of substances which, in healthy people, are capable of producing symptoms like those of the disease being treated
  3. uses electronic monitoring devices to teach a patient to develop conscious control of involuntary bodily functions, such as heart rate and body temperature
  4. incorporates a variety of therapies, such as homeopathy, lifestyle modification, and herbal medicines, to support and maintain the body's ability to heal itself
Correct answer: C
Question 3
The provider contract that the Danube Health Plan has with the Viola Home Health Services Organization states that Danube will use a typical flat rate reimbursement arrangement to compensate Viola for the skilled nursing services it provides to Danube's plan members. A portion of the contract's reimbursement schedule is shown below:
Home Health Licensed Practical Nurse (LPN): $45 per visit or $90 per diem
Home Health Registered Nurse (RN): $50 per visit or $110 per diem
Last month, an LPN from Viola visited a Danube plan member and provided 1Ѕ hours of home healthcare, and an RN from Viola visited another Danube plan member and provided 7 hours of home healthcare. The following statement(s) can correctly be made about Danube's payment to Viola for these services:
  1. Danube most likely owes $90 for the LPN's skilled nursing services and $110 for the RN's skilled nursing services.
  2. Danube's payment amount could be different from the amount called for in the reimbursement schedule if the level of care provided to one of these plan members was significantly different from the level of care normally provided by Viola's RNs and LPNs.
  3. Both A and B
  4. A only
  5. B only
  6. Neither A nor B
Correct answer: C
Question 4
Prior to the enactment of the Balanced Budget Act (BBA) of 1997, payment for Medicare-covered primary and acute care services was based on the adjusted average per capita cost (AAPCC). 
The AAPCC is defined as the
  1. average cost of services delivered to all patients living in a specified geographic region
  2. actuarial value of the deductible and coinsurance amounts for basic Medicare-covered benefits
  3. fee-for-service amount that the Centers for Medicaid and Medicare Services (CMS) would pay for a Medicare beneficiary, adjusted for age, sex, and institutional status
  4. average fixed monthly fee paid by all Medicare enrollees in a specified geographic region
Correct answer: C
Question 5
Social health maintenance organizations (SHMOs) and Programs of All-Inclusive Care for the Elderly (PACE) are federal programs designed to provide coordinated healthcare services to the elderly. Unlike PACE, SHMOs
  1. are reimbursed solely through Medicaid programs
  2. provide extensive long-term care
  3. are reimbursed on a fee-for-service basis
  4. limit benefits to a specified maximum amount
Correct answer: D
Question 6
Franklin Pitt selected a Medicare+Choice option under which he is covered by a catastrophic health insurance policy with a high annual deductible and a $6,000 out-of-pocket expense maximum. CMS pays the premiums for the insurance policy out of the usual Medicare+Choice payment and deposits any difference between the capitated amount and the policy premium in a savings account. Mr. Pitt can use funds in the savings account to pay qualified medical expenses not covered by his insurance policy. At the end of the benefit year, Mr. Pitt can carry any remaining funds into the next benefit year. The Medicare+Choice option Mr. Pitt selected is known as a
  1. coordinate care plan (CCP)
  2. medical savings account (MSA) plan
  3. competitive medical plan (CMP)
  4. Medicare Risk HMO program
Correct answer: B
Question 7
As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy CMS requirements regulating access to covered services. In order to ensure that its network provides adequate access, Brightwell must
  1. Allow enrollees to determine whether they will receive primary care from a physician, nurse practitioner, or other qualified network provider
  2. Base a provider's participation in the network, reimbursement, and indemnification levels on the provider's license or certification
  3. Define its service area according to community patterns of care
  4. Require enrollees to obtain prior authorization for all emergency or urgently needed services
Correct answer: C
Question 8
Stop-loss insurance is designed to protect physicians who face substantial financial risk as a result of physician incentive plans. Medicare + Choice health plans must ensure that a physician has adequate stop-loss protection if the
  1. physician has a patient panel that exceeds 25,000 patients
  2. physician receives a bonus that is based solely on quality of care, patient satisfaction, or physician participation
  3. difference between the physician's maximum potential payments and his or her minimum potential payments is less than 25% of the maximum potential payments
  4. physician is subject to a withhold that is greater than 25% of his or her potential payments
Correct answer: D
Question 9
Medicaid is a joint federal and state program that provides healthcare coverage for low-income, medically needy, and disabled individuals. Under the terms of this joint sponsorship, the
  1. Federal government is responsible for making all claim payments
  2. Federal government is responsible for determining the basic benefits that must be provided to eligible Medicaid beneficiaries
  3. State governments are responsible for setting minimum standards regarding eligibility, benefit coverage, and provider participation and reimbursement
  4. State governments are responsible for establishing overall regulation of the Medicaid program
Correct answer: B
Question 10
Martin Breslin, age 72 and permanently disabled, is classified as dually-eligible. This information indicates that Mr. Breslin qualifies for coverage by both
  1. Medicare and private indemnity insurance, and Medicare provides primary coverage
  2. Medicare and Medicaid, and Medicare provides primary coverage
  3. Medicaid and private indemnity insurance, and Medicaid provides primary coverage
  4. Medicare and Medicaid, and Medicaid provides primary coverage
Correct answer: B

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