최신 AHM-530 무료덤프 - AHIP Network Management

문제1

The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:

A. Does not need as great a variety of provider types or as complex a reimbursement method as does a traditional HMO

B. Most likely provides fewer supportive services than does a traditional HMO, because one of Bruin's goals is to minimize the use of community-based care

C. Receives a payment that is based on reasonable costs and reasonable charges

D. Must provide Medicare participants with standard HMO benefits, as well as with limited long-term care benefits

정답: D

문제2

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: specific-service carve-out

B. Apex: specific-service carve-out Bengal: disease-specific carve-out

C. Apex: disease-specific carve-out Bengal: specialty services carve-out

D. Apex: specific-service carve-out Bengal: specialty services carve-out

정답: D

문제3

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.
The per diem reimbursement method will require Gladspell to pay Ellysium a

A. Fixed rate per enrollee per month

B. Fixed rate for each day a plan member is treated in Ellysium's subacute care facility

C. Discounted charge for all subacute care services given by Ellysium

D. Rate that varies depending on patient category

정답: B

문제4

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. Risk adjustment arrangement

B. Withhold arrangement

C. Disease-specific arrangement

D. Contact capitation arrangement

정답: D

문제5

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. evaluate providers' practice patterns and compliance with the health plan's procedures for the delivery of care

C. all of the above

D. monitor the types of services provided by the health plan's entire provider network

정답: C

문제6

The following statements are about the negotiation process of provider contracting. Three of the statements are true and one of the statements is false. Select the answer choice containing the FALSE statement.

A. The actual signing of the provider contract typically takes place after negotiations are completed.

B. Typically, the health plan and the provider negotiate the reimbursement arrangement between the parties before they negotiate the scope of services and the contract language.

C. While preparing for negotiations, the health plan usually sends the provider an application to join the provider network, a list of credentialing requirements, and a copy of the proposed provider contract, which may or may not include the proposed reimbursement schedule.

D. In general, the ideal negotiating style for provider contracting is a collaborative approach.

정답: B

문제7

By definition, a measure of the extent to which a health plan member can obtain necessary medical services in a timely manner is known as

A. Accessibility

B. Cost-effectiveness

C. Quality

D. Network management

정답: A

문제8

One characteristic of the workers' compensation program is that:

A. indemnity benefits currently account for less than 10% of all workers' compensation benefits

B. workers' compensation coverage is available to all employees, regardless of their eligibility for health insurance coverage

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

정답: B

문제9

The following statements are about the inclusion of unified pharmacy benefits in health plan healthcare packages. Select the answer choice containing the correct statement.

A. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs typically give health plans more control over patient access to prescription drugs.

B. When pharmacy benefits management is incorporated into an health plan's operations as a unified benefit, the health plan establishes pharmacy networks, but a pharmacy benefits management (PBM) company manages their operations.

C. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs make drug therapy interventions for plan members more difficult.

D. Under a unified pharmacy benefit, an health plan cannot use mail-order services to provide drugs to its members.

정답: A

문제10

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. $125.00

B. $111.11

C. $166.67

D. $150.00

정답: D

최신 AHM-530 무료덤프 - AHIP Network Management

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