AHM-530 Exam - Network Management

NEW QUESTION 1

The provider contract that Dr. Laura Cartier has with the Sailboat health plan includes a section known as the recitals. Dr. Cartier's contract includes the following statements:

• A. A statement that identifies the purpose of the contract
• B. A statement that defines in legal terms the parties to the contract
• C. A statement that identifies the Sailboat products to be covered by the contractOf these statements, the ones that are likely to be included in the recitals section of D
• D. Cartier's contract are statements:
• E. A, B, and C
• F. A and B only
• G. A and C only
• H. B and C only

Answer: A

NEW QUESTION 2

The actual number of providers included in a provider network may be based on staffing ratios. Staffing ratios relate the number of

• A. Potential providers in a plan’s network to the number of individuals in the area to be served by the plan
• B. Providers in a plan’s network to the number of enrollees in the plan
• C. Providers outside a plan’s network to the number of providers in the plan’s network
• D. Support staff in a plan’s network to the number of medical practitioners in the plan’s network

Answer: B

NEW QUESTION 3

The provider contract that Dr. Lorena Chau has with the Fiesta Health Plan includes an evergreen clause. The purpose of this clause is to:

• A. Allow Fiesta to change or amend the contract without D
• B. Chau's approval as long as the modifications are made in order to comply with new legal and regulatory requirements
• C. Prohibit D
• D. Chau from encouraging her patients to switch from Fiesta to another health plan
• E. Prohibit D
• F. Chau from encouraging her patients to switch from Fiesta to another health plan
• G. Assure that D
• H. Chau provides Fiesta members with healthcare services in a timely manner appropriate to the member's medical condition

Answer: C

NEW QUESTION 4

Health plans use a variety of sources to find candidates to recruit for their provider networks. In general, two of the most effective methods of finding candidates are through

• A. Word of mouth and on-site training programs
• B. Word of mouth and direct mail
• C. Advertisements in local newspapers and on-site training programs
• D. Advertisements in local newspapers and direct mail

Answer: B

NEW QUESTION 5

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.
The network strategy that Gardenia is using to establish its range of healthcare plans is known as the

• A. network-within-a-network approach
• B. gatekeeper approach
• C. tiered network approach
• D. preferred tier approach

Answer: A

NEW QUESTION 6

A population’s demographic factors—such as income levels, age, gender, race, and ethnicity—can influence the design of provider networks serving that population. With respect to these demographic factors, it is correct to say that

• A. higher-income populations have a higher incidence of chronic illnesses than do lowerincome populations
• B. compared to other groups, young men are more likely to be attached to particular providers
• C. a population with a high proportion of women typically requires more providers than does a population that is predominantly male
• D. Health plans should not recognize, in either the design of networks or the evaluation of provider performance, racial and ethnic differences in the member population

Answer: C

NEW QUESTION 7

Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in

• A. Slower access to BH care for plan members
• B. Increased collaboration between BH providers and PCPs
• C. Fewer specialized BH services for plan members
• D. Decreased continuity of BH care for plan members

Answer: D

NEW QUESTION 8

Most health plan contracts provide an outline of the criteria that a healthcare service must meet in order to be considered “medically necessary.” Typically, in order for a healthcare service to be considered medically necessary, the service provided by a physician or other healthcare provider to identify and treat a member’s illness or injury must be

• A. Consistent with the symptoms of diagnosis
• B. Furnished in the least intensive type of medical care setting required by the member’s condition
• C. In compliance with the standards of good medical practice
• D. All of the above

Answer: D

NEW QUESTION 9

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

• A. are reimbursed solely through Medicaid programs
• B. provide extensive long-term care
• C. are reimbursed on a fee-for-service basis
• D. limit benefits to a specified maximum amount

Answer: D

NEW QUESTION 10

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.
Autumn’s method of reimbursing specialty providers can best be described as a

• A. Disease-specific arrangement
• B. Contact capitation arrangement
• C. Risk adjustment arrangement
• D. Withhold arrangement

Answer: B

NEW QUESTION 11

In health plan pharmacy networks, service costs consist of two components: costs for services associated with dispensing prescription drugs and costs for cognitive services. Cognitive services typically include:

• A. making generic substitutions of drugs
• B. counseling patients about prescriptions
• C. providing patient monitoring
• D. switching prescription drugs to preferred drugs

Answer: B

NEW QUESTION 12

In open panel contracting, there are several types of delivery systems. One such delivery system is the faculty practice plan (FPP). One likely result that a health plan will experience by contracting with an FPP is that the health plan will

• A. be able to select most of the physicians in the FPP
• B. achieve the highest level of cost effectiveness possible
• C. experience limited control over utilization
• D. achieve the most effective case management possible

Answer: C

NEW QUESTION 13

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.
The following statement(s) can correctly be made about Gardenia’s establishment of the PPO and the staff model HMO in its new market:
* 1. When establishing its PPO network, Gardenia most likely initiated outcomes measurement tools and developed collaborative process improvement relationships with providers.
* 2. To avoid high overhead expenses in the early stages of market evelopment, Gardenia’s HMO most likely contracted with specialists and ancillary providers until the plan’s membership grew to a sufficient level to justify employing these specialists.

• A. Both 1 and 2
• B. Neither 1 nor 2
• C. 1 Only
• D. 2 Only

Answer: D

NEW QUESTION 14

The provider contract that Dr. Huang Kwan has with the Poplar Health Plan includes a typical scope of services provision. The medical service that Dr. Kwan provided to Alice Meyer, a Poplar plan member, is included in the scope of services. The following statement(s) can correctly be made about this particular medical service:

• A. D
• B. Kwan most likely was required to seek authorization from Poplar before performing this particular service.
• C. D
• D. Kwan most likely was paid on a FFS basis for providing this service.
• E. Both A and B
• F. A only
• G. B only
• H. Neither A nor B

Answer: D

NEW QUESTION 15

A provider group purchased from an insurer individual stop-loss coverage for primary and specialty care services with an $8,000 attachment point and 10% coinsurance. If the group's accrued cost for the primary and specialty care treatment of one patient is $10,000, then the amount that the insurer would be responsible for reimbursing the provider group for these costs is:

• A. $200
• B. $1,000
• C. $1,800
• D. $9,000

Answer: C

NEW QUESTION 16

From the following answer choices, choose the type of clause or provision described in this situation.
The provider contract between Dr. Olin Norquist and the Granite Health Plan specifies a time period for the party who has breached the contract to remedy the problem and avoid termination of the contract.

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

Answer: A

NEW QUESTION 17
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