AHM-530 AHIP Exam Questions and Free Practice Test

Question 13

- (Topic 2)
The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
The comparative method of evaluation that Azure uses to identify and implement the practices that lead to the best outcomes is known as

A. Case mix analysis

B. Outcomes research

C. Benchmarking

D. Provider profiling

Correct Answer:C

Question 14

- (Topic 2)
The following statement(s) can correctly be made about the Balanced Budget Act (BBA) of 1997:

A. The BBA requires Medicare+Choice organizations to be licensed as non-risk-bearing entities under federal law.

B. The Centers for Medicaid and Medicare Services (CMS) is responsible for implementing the BBA.

C. Both A and B

D. A only

E. B only

F. Neither A nor B

Correct Answer:C

Question 15

- (Topic 1)
The Aegean Health Plan delegated its utilization management (UM) program to the Silhouette IPA. Silhouette, in turn, transferred authority for case management to Brandon Health Services. In this situation, Brandon is best described as the

A. delegator, and Aegean is ultimately responsible for Brandon’s performance

B. delegator, and Silhouette is ultimately responsible for Brandon’s performance

C. subdelegate, and Aegean is ultimately responsible for Brandon’s performance

D. subdelegate, and Silhouette is ultimately responsible for Brandon’s performance

Correct Answer:C

Question 16

- (Topic 1)
From the following answer choices, choose the type of clause or provision described in this situation.
The Aviary Health Plan includes in its provider contracts a clause or provision that places the ultimate responsibility for an Aviary plan member’s medical care on the provider.

A. Cure provision

B. Hold-harmless provision

C. Evergreen clause

D. Exculpation clause

Correct Answer:D

Question 17

- (Topic 1)
One important aspect of network management is profiling, or provider profiling. Profiling is most often used to

A. measure the overall performance of providers who are already participants in the network

B. assess a provider’s overall satisfaction with a plan’s service protocols and other operational areas

C. verify a prospective provider’s professional licenses, certifications, and training

D. familiarize a provider with a plan’s procedures for authorizations and referrals

Correct Answer:A

Question 18

- (Topic 1)
The following statements are about the specialist component of a provider panel. Select the answer choice containing the correct statement.

A. Ideally, a health plan should have every specialist category represented on its provider panel with appropriate geographic distribution.

B. Most specialist contracts do not ensure the provider’s adherence to UM policies set up by the health plan.

C. No-balance-billing clauses are not desirable in health plan contracts with specialists.

D. In geographic regions where there is a shortage of PCPs, a health plan is not permitted to contract with specialists to perform primary care services, even for patients with chronic conditions.

Correct Answer:A

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