AHM-530 AHIP Exam Questions and Free Practice Test

Question 25

- (Topic 2)
The Tuba Health Plan recently underwent an accreditation process under a program known as Accreditation '99, which includes selected Health Employer Data and Information Set (HEDIS) measures. Under Accreditation '99, Tuba received a rating of Excellent. The following statement(s) can correctly be made about this quality assessment of Tuba's operations:

A. In arriving at its rating of Excellent for Tuba, the Accreditation '99 program most likely focused on Tuba's demonstrated results and evaluated the processes that Tuba used to achieve those results.

B. Tuba is required to report all HEDIS results to the NAIC.

C. Both A and B

D. A only

E. B only

F. Neither A nor B

Correct Answer:B

Question 26

- (Topic 1)
The actual number of providers included in a provider network may be based on staffing ratios. Staffing ratios relate the number of

A. Potential providers in a plan’s network to the number of individuals in the area to be served by the plan

B. Providers in a plan’s network to the number of enrollees in the plan

C. Providers outside a plan’s network to the number of providers in the plan’s network

D. Support staff in a plan’s network to the number of medical practitioners in the plan’s network

Correct Answer:B

Question 27

- (Topic 2)
The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan member for covered services is known as:

A. Atermination with cause clause

B. Ahold-harmless clause

C. An indemnification clause

D. Acorrective action clause

Correct Answer:B

Question 28

- (Topic 2)
In health plan pharmacy networks, service costs consist of two components: costs for services associated with dispensing prescription drugs and costs for cognitive services. Cognitive services typically include:

A. making generic substitutions of drugs

B. counseling patients about prescriptions

C. providing patient monitoring

D. switching prescription drugs to preferred drugs

Correct Answer:B

Question 29

- (Topic 1)
Dr. Janet Dubois is a radiologist who practices exclusively at the Rightway Healthcare Center. This information indicates that Dr. Dubois is employed by Rightway as

A. An academic practitioner

B. An independent practitioner

C. Anetwork manager

D. Ahospital-based specialist

Correct Answer:D

Question 30

- (Topic 2)
Dr. Sylvia Cimer and Dr. Andrew Donne are obstetrician/gynecologists who participate in
the same provider network. Dr. Comer treats a large number of high-risk patients, whereas Dr. Donne’s patients are generally healthy and rarely present complications. As a result, Dr. Comer typically uses medical resources at a much higher rate than does Dr. Donne. In order to equitably compare Dr. Comer’s performance with Dr. Donne’s performance, the health plan modified its evaluation to account for differences in the providers’ patient populations and treatment protocols. The health plan modified Dr. Comer’s and Dr. Donne’s performance data by means of

A. Acase mix/severity adjustment

B. An external performance standard

C. Structural measures

D. Behavior modification

Correct Answer:A

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