AHM-250 Online Practice Questions and Answers

During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, fo

A. the angina, the high blood pressure, and the broken ankle

B. the angina and the high blood pressure only

C. none of these conditions

D. the broken ankle only

In large health plans, management functions such as provider recruiting, credentialing, contracting, provider service, and performance management for providers are typically the responsibility of the

A. chief executive officer (CEO)

B. network management director

C. board of directors

D. director of operations

Immediate evaluation and treatment of illness or injury can be provided in any of the following care settings:

A. Hospital emergency departments

B. Physician's offices

C. Urgent care centers

D. If these settings are ranked in order of the cost of providing c

A. A, B, C

B. A, C, B

C. B, C, A

D. C, A, B

Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.

A. The Serenity Healthcare Organization requires a plan member or the provider in charge of the member's care to obtain authorization for inpatient care before the member is admitted to the hospital.

B. UR nurses employed by the Friendship Health Plan monitor length of stay to identify factors that might contribute to unnecessary hospital days.

C. The Optimum Health Group evaluates the medical necessity and appropriateness of proposed services and intervenes, if necessary, to redirect care to a more appropriate care setting.

D. The Axis Medical Group examines provider practice patterns to identify areas in which services are being underused, overused, or misused and designs strategies to prevent inappropriate utilization in the future.

Bart Vereen is insured by both a traditional indemnity health insurance plan, which is his primary plan, and a managed care plan. Both plans have a typical coordination of benefits (COB) provision, but neither plan has a nonduplication of benefits provision

A. 380

B. 130

C. 0

D. 550

In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care.

A. Such intervention can be based on the results of

B. Prospective review

C. Concurrent review

A. A, B, and C

B. A and B only

C. A and C only

D. B only

Specialty services with certain characteristics tend to make good candidates for health plan approaches. One characteristic used to identify a specialty service that may be a good candidate for a health plan approach is that the service should have

A. a defined patient population

B. a complex benefit structure

C. low, stable costs

D. appropriate utilization rates

The application of health plan principles to workers' compensation insurance programs has presented some unique challenges because of the differences between health plan for traditional group healthcare and workers' compensation. One key difference is that

A. limits coverage to eligible employees and excludes part-time employees

B. specifies an annual lifetime benefit maximum on dollar coverage for medical costs

C. provides benefits regardless of the cause of an injury or illness

D. provides benefits for both healthcare costs and lost wages

One of the distinguishing characteristics of healthcare marketing is that many of the markets for health plans are national, not local markets.

A. True

B. False

One non-group market segment to which health plans market health plan products is the senior market, which is comprised mostly of persons over age 65 who are eligible for Medicare benefits. One factor that affects a health plan's efforts to market to the

A. The Centers for Medicare and Medicaid Services (CMS) must approve all marketing materials used by health plans to market health plan products to the Medicare population

B. managed Medicare plans typically require Medicare beneficiaries to purchase Medigap insurance to supplement gaps in coverage

C. managed Medicare plans can refuse to cover persons with certain health problems

D. the CMS prohibits health plans from using telemarketing to market health plan products to the Medicare population

Advantages of EDI over manual data management systems

A. Speed of data refer

B. Loss of data integrity

C. All of the above

D. None of the above

The measures used to evaluate healthcare quality are generally divided into three categories: process, structure, and outcomes. An example of a process measure that can be used to evaluate a health plan's performance is the:

A. Percentage of adult plan members who receive regular medical checkups.

B. Number of plan members contracting an infection in the hospital.

C. Percentage of board certified physicians within the health plan's network.

D. Number of hospital admissions for plan members with certain medical conditions.

The following statements apply to flexible spending arrangements. Select the answer choice that contains the correct statement.

A. FSAs were designed to help increase health insurance coverage among self-employed individuals.

B. Only employers may contribute funds to FSAs.

C. The popularity of FSAs has been limited because funds may not be rolled over from year to year.

D. A popular feature of FSAs is their portability, which allows employees to take the funds with them when they change jobs.

FSA is funded by

A. Employers

B. Employee

C. A and B

The following statements are about accreditation in health plans. Select the answer choice that contains the correct statement.

A. Accreditation is typically performed by a panel of physicians and administrators employed by the health plan under evaluation.

B. All accrediting organizations use the same standards of accreditation.

C. Results of accreditation evaluations are provided only to state regulatory agencies and are not made available to the general public.

D. Accreditation demonstrates to an health plan's external customers that the plan meets established standards for quality care.