AHM-250 Online Practice Questions and Answers

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

Before the Leo Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the

A. receive compensation based on the volume and variety for medical services they perform for Leo plan members, whereas the specialists receive compensation based solely on the number of plan members who are covered for specific services

B. have no financial incentive to practice preventive care or to focus on improving the health of their plan members, whereas the specialists have a positive incentive to help their plan members stay healthy

C. receive from the IPA the same monthly compensation for each Leo plan member under the PCP's care, whereas the specialists receive compensation based on a percentage discount from their normal fees

D. receive compensation based on a fee schedule, whereas the specialists receive compensation based on per diem charges

Allgood Medical, Inc., a health plan, has contracted with Mercy Memorial Hospital to provide inpatient medical services to Allgood's plan members. The terms of the contract specify that Allgood will reimburse Mercy Memorial on the basis of a negotiated ch

A. per diem agreement

B. fee-for-service agreement

C. withhold agreement

D. diagnostic related group (DRG) agreement

For this question, select the answer choice containing the terms that correctly complete the blanks labeled A and B in the paragraph below.

NCQA offers Quality Compass, a national database of performance and accreditation information submitted by managed

A. Health Plan Employer Data and Information Set (HEDIS) mandatory

B. Health Plan Employer Data and Information Set (HEDIS) voluntary

C. ORYX mandatory

D. ORYX voluntary

Greentree Medical, a health plan, is currently recruiting PCPs in preparation for its expansion into a new service area. Abigail Davis, a recruiter for Greentree, has been meeting with Melissa Cortelyou, M.D., in an effort to recruit her as a PCP in Green

A. Greentree is prevented by law from offering a contract to Dr. Cortelyou until the credentialing process is complete

B. any contract signed by Dr. Cortelyou should include a clause requiring the successful completion of the credentialing process within a defined time frame in order for the contract to be effective

C. Greentree must offer a standard contract to Dr. Cortelyou, without regard to the outcome of the credentialing process

D. Greentree will abandon the credentialing process now that Dr. Cortelyou has agreed to participate in Greentree's network

When determining the rates it will charge a small group, the Eagle HMO, a federally qualified HMO, divides its members into classes or groups based on demographic factors such as geography, family composition, and age. Eagle then charges all members of a

A. Retrospective experienced rating.

B. Adjusted community rating (ACR).

C. Pure community rating.

D. Standard community rating.

An HMO's quality assurance program must include

A. A statement of the HMO's goals and objectives for evaluating and improving enrollees' health status

B. Documentation of all quality assurance activities

C. System for periodically reporting program results to the HMO's board of directors, its providers, and regulators

D. All the above

In the CPT system, each service or procedure is identified by

A. Three-digit with decimal point

B. Three-digit

C. Five-digit with decimal point

D. Five-digit

A differences between managed indemnity and traditional indemnity

A. Include precertification and utilization review techniques

B. Both are the same

C. Include network and quality review techniques

D. A and B

The following statement(s) can correctly be made about the Joint Commission on Accreditation of Healthcare Organizations (JCAHO):

A. JCAHO's accreditation process for MCOs and healthcare networks consists of complete on-site surveys conducted every three

B. A only

C. Neither A nor B

D. Both A and B

E. B only