AHM-510 Online Practice Questions and Answers

After conducting a business portfolio analysis, the Acorn Health Plan decided to pursue a harvest strategy with one of its strategic business units (SBUs)-Guest Behavioral Healthcare. By following a harvest strategy with Guest, Acorn most likely is seeking to

A. Maximize Guest's short-term earnings and cash flow

B. Increase Guest's market share

C. Maintain Guest's market position

D. Sacrifice immediate earnings in order to fund Guest's growth

The Wentworth Corporation uses a self-funded plan to provide its employees with healthcare benefits. One consequence of Wentworth's approach to providing healthcare benefits is that self-funding

A. Requires that Wentworth self-administer its healthcare benefit plan

B. Requires that Wentworth pay higher state premium taxes than do insurers and health plans

C. Eliminates the need for Wentworth to pay a risk charge to an insurer or health plan

D. Increases the number of benefit and rating mandates that apply to Wentworth's plan

Several states have adopted clinical practice guidelines for treating workers' compensation injuries. Clinical practice guidelines can best be described as

A. Fee schedules that specify the maximum amount providers may charge for treating workers' compensation patients

B. A utilization management and quality management mechanism designed to aid providers in making decisions about the most appropriate course of treatment for a specific case

C. Detailed plans of medical treatment designed to facilitate a patient's return to the workplace

D. Payment practices that might technically violate the provisions of the anti-kickback statute but that will not be considered illegal and for which providers and health plans will not be subject to penalties

The following statements appear in the Twilight Health Plan's strategic plan:

Increase the percentage of preventive health interventions for total eligible membership during each of the next three calendar years for the following services: mammography, Pap smears, immunizations, and first trimester visits for prenatal mothers

Improve customer satisfaction on an annual basis for each of the next three calendar years, as measured by satisfaction surveys for members, providers, and employer groups

Increase by 30% the number of claims processed by the automated claim payment system and reduce by 10% the cost of paying claims during the next three years

These statements are examples of Twilight's

A. Corporate objectives

B. Company mission

C. Company vision

D. Corporate strategies

Certificate of need (CON) laws apply to health plans in a variety of ways, depending upon the state. By definition, CON laws are laws that are designed to

A. Regulate the construction, renovation, and acquisition of healthcare facilities as well as the purchase of major medical equipment in a geographical area

B. Protect commerce from unlawful restraint of trade, price discrimination, price fixing, reduced competition, and monopolies

C. Determine benefit payments when a person is covered by more than one plan, such as two group health plans

D. License and regulate health plans that wish to establish and operate an HMO

There are several exceptions to the Ethics in Patient Referrals Act and its amendments (the Stark laws), which prohibit a physician from referring Medicare or Medicaid patients for certain designated services or supplies provided by entities in which the physician has a financial interest. Consider whether the situations described below qualify as exceptions to the Stark laws:

Situation A: Dr. Wong is a physician in the Marvel Health Plan's provider network and has a financial relationship with Marvel arising from the health plan's compensation for his services. Marvel is not a prepaid health plan.

Situation B: Dr. Ryder is a physician in the provider network of the Glen Health Plan, which is not a prepaid health plan. In situations of medical necessity, Dr. Ryder refers Glen patients to a physical therapy clinic that leases office space from him.

Situation C: Dr. Yost has a compensation arrangement with a health plan for providing health services under the Medicare+Choice program.

An arrangement that is exempt from the Stark laws is described in

A. All of these situations

B. Situations A and C only

C. Situation B only

D. Situation C only

From the following answer choices, choose the term that best corresponds to this description. The SureQual Group is a group of practicing physicians and other healthcare professionals paid by the federal government to review services ordered or furnished by other practitioners in the same medical fields for the purpose of determining whether medical services provided were reasonable and necessary, and to monitor the quality of care given to Medicare patients.

A. Health insuring organization (HIO)

B. Independent practice association (IPA)

C. Physician practice management (PPM) company

D. Peer review organization (PRO)

In the course of doing business, health plans conduct basic corporate transactions. For example, when a health plan engages in the corporate transaction known as aggressive sourcing, the health plan

A. Chooses to contract with vendors who provide specific functions that would otherwise be performed in-house, such as paying claims

B. Seeks to obtain the best deals from various vendors for equipment, supplies, and services such as telephones, overnight mail, computer hardware and software, and copy machines

C. Merges with one or more companies to form an entirely new company

D. Joins with one or more companies, but retains its autonomy and relies on the other companies to perform specific functions