AHIP Exam Practice Test 01

 

AHIP AHM-540 Practice Quiz Test Part 1

AHIP AHM-540

Examination Preparation Answer Question

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Question-01

One method of transferring the information in electronic medical records (EMRs) is through a health information network (HIN). The following statements are about HINs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

 

A. A HIN may afford a health plan better measurements of outcomes and provider performance.

B. The use of a HIN typically increases a health plan’s exposure to liability for poor care.

C. Most HINs are Internet-based rather than built on proprietary computer networks.

D. Currently, the majority of health plans do not have HINs that are capable of transferring medical records among their network providers.

 

Ans: B.

Question-02

One true statement about state regulation of case management activities is that the majority of states

 

A. have enacted laws that list specific quality management requirements for a case management program

B. consider case management files to be medical records that must be retained for a

specified length of time

C. view case management similarly and follow similar patterns with their laws and regulations

D. have enacted laws or regulations requiring licensure or certification of case managers

 

Ans: B.

Question-03

CMS has developed two prototype programs—Programs of All-inclusive Care for the Elderly (PACE) and the Social Health Maintenance Organization (SHMO) demonstration project—to deliver healthcare services to Medicare beneficiaries. From the answer choices below, select the response that correctly identifies the features of these programs.

A. PACE-annual limits on benefits for nursing home and community-based care SHMO-nolimits on long-term care benefits

B. PACE-provide long-term care only SHMO-provide acute and long-term care

C. PACE-enrollees must be age 65 or older SHMO-enrollees must be age 55 or older

D. PACE-enrollment open to nursing home certifiable Medicare beneficiaries only SHMO- enrollment open to all Medicare beneficiaries

 

Ans: D.

 

Question-04

The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

Medical management programs often require the analysis of many types of data and information.           is an automated process that analyzes variables to help detect patterns and relationships in the data.

 

A. Unbundling

B. Outsourcing

C. Data mining

D. Drilling down

 

Ans: C.

 

Question-05

The American Accreditation HealthCare Commission/URAC (URAC) has an accreditation program specifically for case management services. From the answer choices below, select the response that correctly identifies the type(s) of case management services addressed by URAC’s standards and the type(s) of organizations to which these standards may be applied.

 

 

 

A. Type(s) of Services-on-site services only Type(s) of Organization-health plans only

B. Type(s) of Services-on-site services only Type(s) of Organization-any organization that performs case management functions

C. Type(s) of Services-both telephonic and on-site services Type(s) of Organization-health plans only

D. Type(s) of Services-both telephonic and on-site services Type(s) of Organization-any organization that performs case management functions

 

Ans: D.

 

Question-06

The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self- care most likely would not be appropriate.

 

A. Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area.

B. Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several

times each day.

C. Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility.

D. Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.

 

Ans: A.

 

 

Question-07

Elaine Newman suffered an acute asthma attack and was taken to a hospital emergency department for treatment. Because Ms. Newman’s condition had not improved enough following treatment to warrant immediate release, she was transferred to an observation

care unit. Transferring Ms. Newman to the observation care unit most likely

 

A. resulted in unnecessarily expensive charges for treatment

B. prevented Ms. Newman from receiving immediate attention for her condition

C. gave Ms. Newman access to more effective and efficient treatment than she could have obtained from other providers in the same region

D. allowed clinical staff an opportunity to determine whether Ms. Newman required hospitalization without actually admitting her

 

Ans: D.

 

 

Question-08

The Midwest Health Plan delegated utilization review (UR) activities to the Tri-City Utilization Review Organization. After Tri-City improperly recommended denial of payment for services to a Midwest plan member, the plan member filed suit. The court ruled that Midwest was responsible for Tri-City’s actions because of the relationship between Midwest and Tri-City. This situation is an illustration of a legal concept known as:

 

A. vicarious liability

B. fraud

C. a tying arrangement

D. subdelegation

 

Ans: A

 

 

Question-09

The following statements are about QAPI as it applies to Medicare+Choice plans and

 

Medicaid health plan entities. Select the answer choice containing the correct statement.

 

A. QAPI provides separate sets of standards for Medicaid MCEs and Medicare+Choice plans.

B. Medicaid primary care case management (PCCM) programs are required to comply with all QAPI standards.

C. QISMC standards for quality measurement and improvement apply only to clinical services delivered to Medicare and Medicaid enrollees.

D. States that require Medicaid MCEs to comply with QAPI standards are considered to be in compliance with CMS quality assessment and improvement regulations.

 

Ans: D.

 

 

Question-10

The following statement(s) can correctly be made about medical management considerations for the Federal Employee Health Benefits Program (FEHBP):

 

1.FEHBP plan members who have exhausted the health plan’s usual appeals process for a disputed decision can request an independent review by the Office of Personnel Management (OPM)

2.All health plans that cover federal employees are required to develop and implement patient safety initiatives:

 

A. Both 1 and 2

B. 1 only

C. 2 only

D. Neither 1 nor 2

 

Ans: A.

 

 

Question-11

The following statements are about health plans' complaint resolution procedures (CRPs). Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

 

A. An health plan's CRPs reduce the likelihood of errors in decision making. 

B. CRPs typically provide for at least two levels of appeal for formal appeals. 

C. CRPs include only formal appeals and do not apply to informal complaints.

D. Most complaints are resolved without proceeding through the entire CRP process

 

Ans: C.

Question-12

Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide shouldMr. Farrell become incapacitated.

The document that Mr. Farrell is using to communicate his end-of-life healthcare wishes to his family is known as a:

 

A. medical power of attorney 

B. patient assessment and care plan

C. living will

D. healthcare proxy

 

Ans: C.

 

 

Question-13

One difference between outcomes research and clinical research is that outcomes research

 A. provides an absolute measure of treatment results, whereas clinical research provides a relative measure of results

B. focuses on treatment effectiveness, whereas clinical research focuses on treatment

efficacy

C. examines diseases and treatments in isolation, whereas clinical research considers the effects of changes in health status and quality of life

D. gathers outcomes data from controlled clinical trials, whereas clinical research collects and analyzes clinical, financial, and administrative data

 

Ans: B.

 

 

Question-14

Determine whether the following statement is true or false:

  Immunization programs are a direct means of reducing health plan members’ needs for healthcare services and are typically cost-effective.

 

A. True

B. False

 

Ans: A.

 

 

Question-15

Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans typically use home healthcare include

 

1.The period prior to a hospital admission

2.The period following discharge from a hospital

 

A. Both 1 and 2

B. 1 only

C. 2 only

D. Neither 1 nor 2

 

Ans: A.

 

 

Question-16

Three general categories of coverage policy—medical policy, benefits administration policy, and administrative policy—are used in conjunction with purchaser contracts to determine a health plan’s coverage of healthcare services and supplies. With respect to the characteristics of the three types of coverage policy, it is correct to say that a health plan’s

 

A. medical policy evaluates clinical services against specific benefits language rather than against scientific evidence

B. benefits administration policy determines whether a particular service is experimental or investigational

C. benefits administration policy focuses on both clinical and nonclinical coverage issues

D. administrative policy contains the guidelines to be followed when handling member and provider complaints and disputes

 

Ans: D.

 

 

Question-17

Occasionally, employers combine workers’ compensation, group healthcare, and disability programs into an integrated product known as 24-hour coverage. One true statement about 24-hour coverage is that it typically:

 

A. increases administrative costs 

B. requires plans to maintain separate databases of patient care information

C. exempts plans from complying with state workers’ compensation regulations 

D. allows plans to apply disability management and return-to-work techniques to nonoccupational conditions

 

Ans: D.

 

 

Question-18

Private employers are key purchasers of health plan services. The following statement(s) can correctly be made about employer expectations about the quality and cost- effectiveness of healthcare services:

 

1. For both health maintenance organizations (HMOs) and non-HMO plans, employers typically have access to accreditation results and performance measurement reports to help them evaluate the quality of healthcare and service

2. Because of employers’ concern about the quality and costs of healthcare services available through health plans, direct contracting has become a dominant model among employers who sponsor health benefit programs for their employees

 

A. Both 1 and 2 

B. 1 only

C. 2 only

D. Neither 1 nor 2

 

Ans: D.

 

 

Question-19

Designing effective medical management programs for Medicare beneficiaries requires an understanding of the unique health needs of the Medicare population. One characteristic of Medicare beneficiaries is that they typically:

 

A. do not experience mental health problems 

B. consume more than half of all prescription drugs

C. are likely to equate quality with the technical aspects of clinical procedures

D. require longer and more costly recovery periods following acute illnesses or injuries than does the general population

 

Ans: D.

 

 

Question-20

The following statement(s) can correctly be made about performance measurement systems:

 

1.The most difficult purpose for a performance measurement system to address is tomeasure changes in outcomes caused by modifications in administrative or clinical

treatment processes

2.A health plan needs different performance measurement systems to evaluate its administrative services and the clinical performance of its providers

 

A. Both 1 and 2

B. 1 only

C. 2 only

D. Neither 1 nor 2

 

Ans: C.

 

 

Question-21

The following statements are about disease management programs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

 

A. The focus of disease management is on responding to the needs of individual members for extensive, customized healthcare supervision.

B. Disease management programs serve to improve both clinical and financial outcomes

for healthcare services related to chronic conditions.

C. Tools such as preventive care, self-care, and decision support programs are used to support both case management and disease management.

D. Disease management programs apply to both diseases and medical conditions that are not diseases, such as high-risk pregnancy, severe burns, and trauma.

 

Ans: A.

 

 

Question-22

Increased demands for performance information have resulted in the development of various health plan report cards. With respect to most of the report cards currently available, it is correct to say:

 

A. that they are focused primarily on health maintenance organization (HMO) plans

B. that they are based on data collected for the Health Plan Employer Data and Information Set (HEDIS) 3.0

C. that they are used to rank the performance of various health plans

D. all of the above

 

Ans: D.

 

 

Question-23

By definition, the development and implementation of parameters for the delivery of healthcare services to a health plan’s members is known as:

 

A. utilization management (UM)

B. quality management (QM)

C. care management

D. clinical practice management

 

Ans: D.

 

 

Question-24

Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.

The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen. 

Greenhouse’s prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).

 

A. open / mandatory

B. open / voluntary

C. closed / mandatory

D. closed / voluntary

 

Ans:C.

 

 

Question-25

In order to achieve changes in outcomes, health plans make changes to existing structures and processes. The introduction of preauthorization as an attempt to control overuse of services is an example of a reactive change. Reactive changes are typically

 

A. both planned and controlled 

B. planned, but they are rarely controlled 

C. controlled, but they are rarely planned 

D. neither planned nor controlled

 

Ans: C.

 

 

Question-26

Accreditation is intended to help purchasers and consumers make decisions about healthcare coverage. The following statements are about accreditation. Select the answer choice containing the correct statement.

 

A. At the request of health plans, accrediting agencies gather the data needed for accreditation.

B. Most purchasers and consumers review accreditation results when making decisions to

purchase or enroll in a specific health plan.

C. Accreditation is typically conducted by independent, not-for-profit organizations.

D. All health plans are required to participate in the accreditation process.

 

Ans: C.

 

 

Question-27

Comparing the quality of managed Medicare programs with the quality of FFS Medicare programs is often difficult. Unlike FFS Medicare, managed Medicare programs

 

A. can measure and report quality only at the provider level 

B. use a single system to deliver services to all plan members

C. provide an organizational focus for accountability

D. can use the same performance measures for all products and plans

 

Ans: C.

 

 

Question-28

The case management program director at the Nova Health Plan calculated the program’s ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:

 

Administrative costs for case management ..........$40,000 

Actual medical care expenses for patients under case management ..........$680,000 

Projected medical care expenses for the same patients without case management

..........$900,000

 

This information indicates that, for the previous quarter, Nova’s ratio of medical expense savings to case management administrative costs was

 

A. 0.71/1 

B. 0.80/1

C. 5.50/1

D. 1.25/1

 

Ans: C.

 

 

Question-29

In order for a health plan’s performance-based quality improvement programs to be effective, the desired outcomes must be:

A. achievable within a specified timeframe

B. defined in terms of multiple results

C. expressed in subjective, qualitative terms

D. all of the above

 

Ans: A.

 

 

Question-30

he following statement(s) can correctly be made about the scope of case management:

 

1.Case management incorporates activities that may fall outside a health plan’s typical responsibilities, such as assessing a member’s financial situation 

2.Case management generally requires a less comprehensive and complex approach to a course of care than does utilization review 

3.Case management is currently applicable only to medical conditions that require inpatient hospital care and are categorized as catastrophic in terms of health and/or costs

 

A. All of the above 

B. 1 and 2 only

C. 2 and 3 only 

D. 1 only

 

Ans: D.

 

 

Question-31

Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services

 

A. must be offered as separate supplemental benefits or separate products

B. lack clinical trials to evaluate their safety and effectiveness

C. are not covered by state or federal consumer protection statutes

D. focus on a specific illness, injury, or symptom rather than on the whole body

 

Ans: B.

 

 

Question-32

The Riverside Health Plan is considering the following provider compensation options to use in its contracts with several provider groups and hospitals:

 

1. A discounted fee-for-service (DFFS) payment system  

2. A case rate system  

3. Capitation

 

If Riverside wants to use only those compensation methods that encourage the efficient use of resources, then the compensation method(s) that Riverside should consider for its new contracts include

 

A. 1, 2, and 3 

B. 1 and 2 only 

C. 2 and 3 only 

D. 3 only

 

Ans: C.

 

 

Question-33

Health plans often use accreditation as a means of evaluating the quality of care delivered to plan members. Accreditation of subacute care providers is available from the 

 

A. National Committee for Quality Assurance (NCQA) 

B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

C. American Accreditation HealthCare Commission/URAC (URAC)

D. Foundation for Accountability (FACCT)

 

Ans: B.

 

 

Question-34

Most health plans require a PCP referral or precertification for CAM benefits.

 

A. True 

B. False

 

Ans: B.

 

 

Question-35

For this question, if answer choices (A) through (C) are all correct, select answer choice 

(D). Otherwise, select the one correct answer choice. 

Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say:

 

A. that the construction of a data warehouse is quick and simple 

B. that a data warehouse addresses the problems associated with multiple data management systems

C. that a data warehouse stores only current data

D. all of the above

 

Ans: B.

 

 

Question-36

Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the:

 

A. lack of qualified providers in provider networks

B. lack of resources necessary to establish case management programs for patients with complex conditions

C. unstable eligibility status of Medicaid recipients

D. inability of Medicaid recipients to change health plans or PCPs

 

Ans: C.

 

 

Question-37

The paragraph below contains two pairs of phrases enclosed in parentheses. Select the phrase in each pair that correctly completes the paragraph. The select the answer choice containing the two phrases you have selected.

Calvin Montrose, age 75, has difficulty performing basic self-care activities, such as bathing, dressing, and eating, without assistance. This information indicates that Mr. Montrose needs assistance with (activities of daily living / instrumental activities of daily living) that are used to measure his (functional status / health status).

 

 

 A. activities of daily living / functional status

 B. activities of daily living / health status

C. instrumental activities of daily living / functional status

D. instrumental activities of daily living / health status

 

Ans: A.

 

 

Question-38

Patricia McLeod is a member of the Enterprise Health Plan, which operates in State X. Ms. McLeod is scheduled to undergo a unilateral mastectomy for the treatment of breast cancer. The surgical procedure will be performed by Dr. Kim Lee, a surgical oncologist. Based on Enterprise’s medical policy, the contract with the purchaser, and Ms. McLeod’s medical condition, Enterprise’s UR staff have determined that the appropriate course of care for Ms. McLeod includes a 24-hour stay in the hospital following her surgery. State X, however,has a benefit mandate specifying health plan coverage for 48 hours of inpatient post- mastectomy care. In this situation, the length of hospital stay for which Enterprise must offer coverage is

 

A. the length of stay deemed appropriate by Dr. Lee

B. the 24-hour stay determined to be appropriate by Enterprise’s UR staff

C. the length of stay deemed appropriate by Ms. McLeod

D. the 48-hour length of stay specified by State X

 

Ans: D.

 

 

Question-39

Acute care refers to healthcare services for medical problems that

  

A. are expected to continue for a minimum of 30 days

B. are typically treated in a provider’s office or outpatient facility 

C. require prompt, intensive treatment by healthcare providers 

D. require low utilization of resources

 

Ans: C.

 

 

Question-40

The Medicaid population can be divided into subgroups based on their relative size and the costs of providing benefits. From the answer choices below, select the response that correctly identifies the subgroups that represent the largest percentages of the total Medicaid population and of total Medicaid expenditures. Largest % of Medicaid Population- Largest % of Medicaid Expenditures-

 

A. Largest % of Medicaid Population-dual eligibles Largest % of Medicaid Expenditures- children and low-income adults.

B. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for MedicareLargest % of Medicaid Expenditures-dual eligible.

C. Largest % of Medicaid Population-children and low-income adults Largest % of Medicaid. Expenditures-chronically ill or disabled individuals not eligible for Medicare.

D. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for Medicare Largest % of Medicaid Expenditures-children and low-income adults

 

Ans: C.

 

 

 

 

Question-41

Some health plans administer a questionnaire known as the Behavioral Risk Factor Surveillance System (BRFSS) as part of their health risk assessment (HRA) processes. The following statements are about the BRFSS. If statements (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct statement.

 

 

A. This questionnaire was designed specifically for use by health plans.

B. Each health plan must use the same form of the questionnaire, with no additions or modifications.

C. This questionnaire monitors the prevalence of the major behavioral risks associated with illness and injury among adults.

D. All of the above statements are correct.

 

Question-42

The following statements are about the use of hospitalists to manage inpatient care. Select the answer choice containing the correct statement.

 

A. A patient who has been transferred to a hospitalist for management of inpatient care usually continues to receive care from the hospitalist after discharge.

B. Hospitalists are used primarily to manage care for obstetric, pediatric, and oncology

patients.

C. In order to serve as a hospitalist, a physician must have a background in critical care medicine.

D. Hospitalists typically spend at least one-quarter of their time in a hospital setting.

 

Ans: D.

 

 

Question-43

PBMs are accredited by the same organizations that accredit health plans.

 

A. True 

B. False

 

Ans: B.

 

 

Question-44

As a follow-up to a performance improvement plan for member services, the Stellar Health Plan conducted an evaluation of the success of the plan. Stellar conducted its evaluation as the plan was being carried out. The evaluation focused on specific activities and assessed the relative importance of those activities to the plan as a whole. This information indicates that Stellar’s evaluation of the plan was both

 

A. concurrent and formative

B. oncurrent and summative

C. retrospective and formative

D. retrospective and summative

 

Ans: A.