AHM-250 AHIP Exam Questions and Free Practice Test

Question 61

- (Topic 2)
Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involves

A. ascertaining that physicians in the plan have the necessary and appropriate credentials to prescribe medications

B. compiling data on physician prescribing patterns and comparing physicians' actual prescribing patterns to expected patterns within select drug categories

C. monitoring patient-specific drug problems through concurrent and retrospective review

D. establishing protocols that require physicians to obtain certification of medical necessity prior to drug dispensing

Correct Answer:B

Question 62

- (Topic 2)
Janet Riva is covered by a indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred
$2,500 in medical expenses that were covered by her health plan. She incurred

A. $1,750

B. $1,800

C. $2,000

D. $2,250

Correct Answer:B

Question 63

- (Topic 1)
In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known

A. dual choice

B. cost shifting

C. accreditation

D. defensive medicine

Correct Answer:B

Question 64

- (Topic 2)
The data evaluation stage of utilization review (UR) includes both administrative reviews and medical reviews. One true statement about these types of reviews is that:

A. An administrative review must be conducted by a health plan staff member who is a medical professional.

B. The primary purpose of an administrative review is to evaluate the appropriateness of a proposed medical service.

C. UR staff members typically conduct a medical review of a proposed medical service before they conduct an administrative review for that same service.

D. One purpose of a medical review is to evaluate the medical necessity of a proposed medical service.

Correct Answer:D

Question 65

- (Topic 3)
The HMO Act of 1973 was significant in that the Act

A. mandated certain requirements that all HMOs had to meet in order to conduct business

B. required that all HMOs be licensed as insurance companies

C. offered HMOs federal financial assistance through grants and loans, and provided access to the employer-based insurance market

D. encouraged the use of pre-existing condition exclusion provisions in all HMO contracts

Correct Answer:C

Question 66

- (Topic 1)
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. Such intervention can be based on the results of

A. Prospective review

B. Concurrent review

C. B and C only

D. A, B, and C

E. A and B only

F. A and C only

G. B only

Correct Answer:B

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