AHM-530 AHIP Exam Questions and Free Practice Test

Question 7

- (Topic 1)
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. $111.11

B. $125.00

C. $150.00

D. $166.67

Correct Answer:C

Question 8

- (Topic 1)
For this question, if answer choices (A) through C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Understanding the level of health plan penetration in a particular market can help a health plan determine which products are most appropriate for that market. Indicators of a mature health plan market include

A. Areduction in the rate of growth in health plan premium levels

B. Areduction in the level of outcomes management and improvement

C. An increase in the rate of inpatient hospital utilization

D. All of the above

Correct Answer:A

Question 9

- (Topic 1)
The following statements are about factors that health plans should consider as they develop provider networks in rural and urban markets. Three of the statements are true, and one of the statements is false. Select the answer choice that contains the FALSE statement.

A. Compared to providers in urban areas, providers in rural areas are less likely to offer discounts to health plans in exchange for directed patient volume.

B. In urban areas, limiting the number of specialists on a panel usually affects the network’s market appeal more than does limiting the number of primary care physicians.

C. The greatest opportunity to create competition in rural areas is among the specialty providers in other nearby communities.

D. Typically, hospital contracting is easier in urban areas than in rural areas.

Correct Answer:B

Question 10

- (Topic 2)
The BBA of 1997 specifies the ways in which a Medicare+Choice plan can establish and use provider networks. A Medicare+Choice plan that operates as a private fee for service (PFFS) plan is allowed to

A. limit the size of its network to the number of providers necessary to meet the needs of its enrollees

B. require providers to accept as payment in full an amount no greater than 115% of the Medicare payment rate

C. refuse payment to non-network providers who submit claims for Medicare-coveredexpenses

D. shift all risk for Medicare-covered services to network providers

Correct Answer:B

Question 11

- (Topic 2)
The Aztec Health Plan has a variety of organizational committees related to quality and utilization management. These committees include the medical advisory committee, the credentialing committee, the utilization management committee, and the quality management committee. Of these committees, the one that most likely is responsible for providing oversight of Aztec's inpatient concurrent review process is the:

A. medical advisory committee

B. credentialing committee

C. utilization management committee

D. quality management committee

Correct Answer:C

Question 12

- (Topic 1)
Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in

A. Slower access to BH care for plan members

B. Increased collaboration between BH providers and PCPs

C. Fewer specialized BH services for plan members

D. Decreased continuity of BH care for plan members

Correct Answer:D

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