AHM-530 Exam - Network Management

NEW QUESTION 1

Dr. Eve Barlow is a specialist in the Amity Health Plan’s provider network. Dr. Barlow’s provider contract with Amity contains a typical most-favored-nation arrangement. The purpose of this arrangement is to

• A. Require D
• B. Barlow and Amity to use arbitration to resolve any disputes regarding the contract
• C. Specify that the contract is to be governed by the laws of the state in which Amity has its headquarters
• D. Require D
• E. Barlow to charge Amity her lowest rate for a medical service she has provided to an Amity plan member, even if the rate is lower than the price negotiated in the contract
• F. State that the contract creates an employment or agency relationship, rather than an independent contractor relationship, between D
• G. Barlow and Amity

Answer: C

NEW QUESTION 2

The Avignon Company discontinued its contract with a traditional indemnity insurer and contracted exclusively with the Minaret Health Plan to provide the sole healthcare plan to Avignon’s employees. By agreeing to an exclusive contract with Minaret, Avignon has entered into a type of healthcare contract known as

• A. a carrier guarantee arrangement
• B. open access
• C. total replacement coverage
• D. selective contract coverage

Answer: C

NEW QUESTION 3

The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.
If the Ellysium subacute care unit is typical of most hospital-based subacute skilled nursing units, then this unit could be used for patients who no longer need to be in the hospital’s acute care unit but who still require

• A. Daily medical care and monitoring
• B. Regular rehabilitative therapy
• C. Respiratory therapy
• D. All of the above

Answer: D

NEW QUESTION 4

Health plans often negotiate compensation arrangements that transfer some or all of the financial risk associated with delivering healthcare services to network providers. The following statements are about these compensation arrangements. Select the answer choice containing the correct statement.

• A. A per diem system typically places a healthcare facility at risk for controlling utilization and costs internally.
• B. One likely reason that an health plan would use a fee schedule system to compensate providers is that this system transfers most of the financial risk to the provider.
• C. Under a salary system, a provider assumes no service risk.
• D. The use of a FFS or a salary system allows an health plan to transfer a greater proportion of financial risk to providers than does the use of capitation.

Answer: A

NEW QUESTION 5

One type of fee schedule payment system assigns a weighted unit value for each medical procedure or service based on the cost and intensity of that service. Under this system, the unit values for procedural services are generally higher than the unit values for cognitive services. This system is known as a

• A. Wrap-around payment system
• B. Relative value scale (RVS) payment system
• C. Resource-based relative value scale (RBRVS) system
• D. Capped fee system

Answer: B

NEW QUESTION 6

In most states, workers’ compensation is first-dollar and last-dollar coverage, which means thatworkers’ compensation programs

• A. Can place limits on the benefits they will pay for a given claim
• B. Can deny coverage for work-related illness or injury if the employer is not at fault
• C. Must pay 100% of work-related medical and disability expenses
• D. Can hold employers liable for additional amounts that result from court decisions

Answer: C

NEW QUESTION 7

A provider contract describes the responsibilities of each party to the contract. These responsibilities can be divided into provider responsibilities, health plan responsibilities, and mutual obligations. Mutual obligations typically include

• A. provisions for marketing the plan’s product
• B. payment arrangements between the plan and the provider
• C. verification of the plan’s eligibility to do business
• D. management of the contents of members’ medical records

Answer: B

NEW QUESTION 8

Partial capitation is one common approach to capitation. One typical characteristic of partial capitation is that it:

• A. Includes only primary care services
• B. Covers such services as immunizations and laboratory tests
• C. Can be used only if the provider's panel size is less than 50 providers
• D. Covers such services as cardiology and orthopedics

Answer: A

NEW QUESTION 9

The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline.
Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn’s PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn’s dermatology services fund for the first quarter was $15,000. During the quarter, Autumn’s PCPs made 90 referrals, and 20 of these referrals were classified as complicated.
In determining the first quarter payment to dermatologists, Autumn would accurately calculate the value of each referral point to be

• A. $111.11
• B. $125.00
• C. $150.00
• D. $166.67

Answer: C

NEW QUESTION 10

One reason that an health plan would want to use the actual acquisition cost (AAC) pricing system to calculate its drug costs is that, of the systems commonly used to calculate drug costs, the AAC system

• A. Provides the lowest level of cost for the health plan
• B. Most closely represents what pharmacies are actually charged for prescription drugs
• C. Offers the best control over multiple-source pharmaceutical products
• D. Is the least expensive pricing system for the health plan to implement

Answer: A

NEW QUESTION 11

The Tuba Health Plan recently underwent an accreditation process under a program known as Accreditation '99, which includes selected Health Employer Data and Information Set (HEDIS) measures. Under Accreditation '99, Tuba received a rating of Excellent. The following statement(s) can correctly be made about this quality assessment of Tuba's operations:

• A. In arriving at its rating of Excellent for Tuba, the Accreditation '99 program most likely focused on Tuba's demonstrated results and evaluated the processes that Tuba used to achieve those results.
• B. Tuba is required to report all HEDIS results to the NAIC.
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: B

NEW QUESTION 12

The provider contracts that the Indigo Health Plan has with its providers include a clause which states that Indigo's denial of payment for a certain medical procedure does not constitute a medical opinion and is not intended to interfere with the provider-patient relationship. This information indicates that Indigo's provider contracts include:

• A. A business confidentiality clause.
• B. A scope of services clause.
• C. An informed refusal clause.
• D. An exculpation clause.

Answer: D

NEW QUESTION 13

When the Rialto Health Plan determines which of the emergency services received by its plan members should be covered by the health plan, it is guided by a standard which describes emergencies as medical conditions manifesting themselves by acute symptoms of sufficient severity (including severe pain) such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy. This standard, which was adopted by the NAIC in 1996, is referred to as the

• A. medical necessity standard
• B. prudent layperson standard
• C. “all-or-none” standard
• D. reasonable and customary standard

Answer: B

NEW QUESTION 14

From the following answer choices, choose the type of clause or provision described in this situation.
The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.

• A. Cure provision
• B. Hold-harmless provision
• C. Evergreen clause
• D. Exculpation clause

Answer: C

NEW QUESTION 15

Some states have enacted any willing provider laws. From the perspective of the health plan industry, one drawback of any willing provider laws is that they often result in a reduction of a plan’s

• A. Premium rates
• B. Ability to monitor utilization
• C. Number of primary care providers (PCPs)
• D. Number of specialists and ancillary providers

Answer: B

NEW QUESTION 16

To protect providers against business losses, many health plan-provider contracts include carve-out provisions to help providers manage financial risk. The following statements are examples of such provisions:
The Apex Health Plan carves out immunizations from PCP capitations. Apex compensates PCPs for immunizations on a case rate basis.
The Bengal Health Plan carves out behavioral healthcare services from the scope of PCP services because these services require specialized knowledge and skills that most PCPs do not possess.
From the answer choices below, select the response that best identifies the types of carve- outs used by Apex and Bengal.

• A. Apex: disease-specific carve-out Bengal: specialty services carve-out
• B. Apex: disease-specific carve-out Bengal: specific-service carve-out
• C. Apex: specific-service carve-out Bengal: specialty services carve-out
• D. Apex: specific-service carve-out Bengal: disease-specific carve-out

Answer: C

NEW QUESTION 17
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