AHM-530 Exam - Network Management

NEW QUESTION 1

Assume that the national average cost per covered employee for PPO rental networks is
$3 per member per month (PMPM) and that the average monthly healthcare premium PMPM is $300. This information indicates that, if the number of health plan members is 10,000, then the annual network rental cost to the health plan would be:

• A. $30,000
• B. $360,000
• C. $9,000,000
• D. $12,000,000

Answer: B

NEW QUESTION 2

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service
(DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:

• A. D
• B. Enberg's young patients receive appropriate immunizations at the right ages
• C. D
• D. Enberg's young patients receive appropriate immunizations at the right ages
• E. The condition of one of D
• F. Enberg's patients improved after the patient received medical treatment from D
• G. Enberg
• H. D
• I. Enberg's procedures are adequate for ensuring patients' access to medical care

Answer: A

NEW QUESTION 3

In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it

• A. Applies to group health insurance plans only
• B. Limits the length of a health plan’s pre-existing condition exclusion period for a previously covered individual to a maximum of six months after enrollment.
• C. Guarantees access to healthcare coverage for small businesses and previously covered individuals who meet specified eligibility requirements.
• D. Guarantees renewability of group and individual health coverage, provided the insureds are still in good health

Answer: C

NEW QUESTION 4

Network managers rely on a health plan’s claims administration department for much of the information needed to manage the performance of providers who are not under a capitation arrangement. Examining claims submitted to a health plan’s claims administration department enables the health plan to

• A. determine the number of healthcare services delivered to plan members
• B. monitor the types of services provided by the health plan’s entire provider network
• C. evaluate providers’ practice patterns and compliance with the health plan’s procedures for the delivery of care
• D. all of the above

Answer: D

NEW QUESTION 5

As part of the credentialing process, many health plans use the National Practitioner Data Bank (NPDB) to learn information about prospective members of a provider network. One true statement about the NPDB is that:

• A. It is maintained by the individual states
• B. It primarily includes information about any censures, reprimands, or admonishments against any physicians who are licensed to practice medicine in the United States
• C. The information in the NPDB is available to the general public
• D. It was established to identify and discipline medical practitioners who act unprofessionally

Answer: D

NEW QUESTION 6

The National Committee for Quality Assurance (NCQA) has integrated accreditation with Health Employer Data and Information Set (HEDIS) measures into a program called Accreditation ’99. One statement that can correctly be made about these accreditation standards is that

• A. Health plans are required by law to report HEDIS results to NCQA
• B. HEDIS restricts its reporting criteria to a narrow group of quantitative performance measures, while NCQA includes a broad range of qualitative performance measures
• C. Private employer groups purchasing health care coverage increasingly require both NCQA accreditation and HEDIS reporting
• D. HEDIS includes measures of a health plan’s effectiveness of care rather than its cost of care

Answer: C

NEW QUESTION 7

Grant Pelham is covered by both a workers’ compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.
Because Mr. Pelham was injured on the job, he is entitled to receive benefits through workers’ compensation. Under the terms of the state-mandated exclusive remedy doctrine included in the workers’ compensation agreement, Mr. Pelham will most likely be prohibited from

• A. Receiving workers’ compensation benefits unless he can show that the employer was at fault for his injury
• B. Obtaining care from providers who are not members of a workers’ compensation network
• C. Suing his employer for additional benefits
• D. Claiming benefits from both workers’ compensation and his group health plan

Answer: C

NEW QUESTION 8

The following statements describe two types of HMOs:
The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.
The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.
Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.
Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:
The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents
per tablet for this drug.
The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.
From the following answer choices, select the response that best identifies Elm and Treble:

• A. Elm: open access (OA) HMO Treble: direct access HMO
• B. Elm: open access (OA) HMO Treble: gatekeeper HMO
• C. Elm: direct access HMO Treble: open access (OA) HMO
• D. Elm: direct access HMO Treble: gatekeeper HMO

Answer: C

NEW QUESTION 9

The following statements are about incentive programs used for providers. Select the answer choice containing the correct statement.

• A. Risk pools based on aggregate provider performance eliminate problems associated with “free riders.”
• B. A hospital bonus pool is usually split between the health plan and the PCPs.
• C. Bonus pools based on the performance of specific providers are usually easier to administer than those based on the performance of the plan as a whole.
• D. For providers, withhold arrangements eliminate the risk of losing base income.

Answer: B

NEW QUESTION 10

If a member of the Green Health Plan reasonably believes that a provider in Green's provider network was acting as Green's employee or agent while providing negligent care, then the member may have cause to bring action against the health plan. This legal concept is known as vicarious liability. Steps that Green can take to reduce its exposure to vicarious liability claims include:

• A. Placing restrictions on provider-member communication involving treatment decisions.
• B. Implementing risk management and quality assurance programs for its provider network.
• C. Including in its provider agreements and marketing and membership literature a statement that members of the Green provider network are not independent contractors.
• D. All of the above.

Answer: B

NEW QUESTION 11

Dr. Leona Koenig removed the appendix of a plan member of the Helium health plan. In order to increase the level of reimbursement that she would receive from Helium, Dr. Koenig submitted to the health plan separate charges for the preoperative physical examination, the surgicalprocedure, and postoperative care. All of these charges should have been included in the code for the surgical procedure itself. Dr. Koenig's submission is a misuse of the coding system used by health plans and is an example of:

• A. Upcoding
• B. A wrap-around
• C. Churning
• D. Unbundling

Answer: D

NEW QUESTION 12

The Zephyr Health Plan identifies members for whom subacute care might be an appropriate treatment option. The following individuals are members of Zephyr:
Selena Tovar, an oncology patient who requires radiation oncology services, chemotherapy, and rehabilitation.
Dwight Borg, who is in excellent health except that he currently has sinusitis.
Timothy O'Shea, who is beginning his recovery from brain injuries caused by a stroke. Subacute care most likely could be an appropriate option for:

• A. M
• B. Tovar, M
• C. Borg, and M
• D. O'Shea
• E. M
• F. Tovar and M
• G. O'Shea only
• H. M
• I. O'Shea only
• J. M
• K. Borg only

Answer: B

NEW QUESTION 13

One characteristic of the workers' compensation program is that:

• A. workers' compensation coverage is available to all employees, regardless of their eligibility for health insurance coverage
• B. indemnity benefits currently account for less than 10% of all workers' compensation benefits
• C. workers' compensation programs in most states require eligible employees to obtain medical treatment only from members of a provider network
• D. workers' compensation programs include deductibles and coinsurance requirements

Answer: A

NEW QUESTION 14

The Octagon Health Plan includes a typical indemnification clause in its provider contracts. The purpose of this clause is to require Octagon’s network providers to

• A. Agree not to sue or file claims against an Octagon plan member for covered services
• B. Reimburse Octagon for costs, expenses, and liabilities incurred by the health plan as a result of a provider’s actions
• C. Maintain the confidentiality of the health plan’s proprietary information
• D. Agree to accept Octagon’s payment as payment in full and not to bill members for anything other than contracted copayments, coinsurance, or deductibles

Answer: B

NEW QUESTION 15

The Adobe Health Plan complies with all of the provisions of the Newborns' and Mothers' Health Protection Act (NMHPA) of 1996. Kristen Netzger, an Adobe enrollee, was hospitalized for a cesarean delivery. Amy Davis, also an Adobe enrollee, was hospitalized for a normal delivery. From the following answer choices, select the response that indicates the minimum length of time for which Adobe, under NMHPA, most likely must provide benefits for the hospitalizations of Ms. Netzger and Ms. Davis.

• A. M
• B. Netzger = 48 hours M
• C. Davis = 48 hours
• D. M
• E. Netzger = 72 hours M
• F. Davis = 72 hours
• G. M
• H. Netzger = 96 hours M
• I. Davis = 48 hours
• J. M
• K. Netzger = 96 hours M
• L. Davis = 72 hours

Answer: C

NEW QUESTION 16

Health plan contract negotiations with an integrated delivery system (IDS) or a hospital are usually lengthier and more complex than negotiations with a single-specialty provider.

• A. True
• B. False

Answer: A

NEW QUESTION 17
......