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AHIP AHM-250 Exam Practice Questions (P. 5)

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Question #41
Dr. Milton Ware, a physician in the Riverside MCO's network of providers, is reimbursed under a fee schedule arrangement for medical services he provides to Riverside members. Dr. Ware's provider contract with Riverside contains a typical no-balance billing provision. One purpose of this provision is to:
  1. A
    prevent Dr. Ware from requiring a Riverside member to pay any coinsurance, copayment, or deductibles that the member would normally pay under Riverside's plan
  2. B
    require Dr. Ware to accept the amount that Riverside pays for medical services as payment in full and not to bill plan members for additional amounts
  3. C
    prevent Dr. Ware from seeking compensation from patients if Riverside fails to compensate him because of the MCO's insolvency
  4. D
    prevent Dr. Ware from billing a Riverside member for medical services that are not included in Riverside's plan

Correct Answer:
B

Question #42
Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. The primary purpose of this clause is to:
  1. A
    State that Dr. Aldridge's provider contract with Badger will automatically terminate if he loses his medical license or hospital privileges.
  2. B
    Specify a time period during which the party that breaches the provider contract must remedy the problem in order to avoid termination of the contract.
  3. C
    Give Dr. Aldridge the right to appeal Badger's decision if he is terminated with cause from Badger's provider network.
  4. D
    Specify that Badger can terminate this provider contract without providing a reason, but only if Badger gives Dr. Aldridge at least 90-days' notice of its intent to terminate the contract.

Correct Answer:
C

Question #43
During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, former broken ankle, and high blood pressure. Which of these conditions apply?
  1. A
    the angina, the high blood pressure, and the broken ankle
  2. B
    the angina and the high blood pressure only
  3. C
    none of these conditions
  4. D
    the broken ankle only

Correct Answer:
A

Question #44
During the risk assessment process for a traditional indemnity group insurance health plan, group underwriters consider such characteristics as a group’s geographic location, the size and gender mix of the group, and the level of participation in the group:
  1. A
    Healthcare costs are typically higher in rural areas than in large urban areas.
  2. B
    The morbidity rate for males is higher than the morbidity rate for females.
  3. C
    The larger the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.
  4. D
    All of the above

Correct Answer:
C

Question #45
Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.
  1. A
    The Serenity Healthcare Organization requires a plan member or the provider in charge of the member's care to obtain authorization for inpatient care before the member is admitted to the hospital.
  2. B
    UR nurses employed by the Friendship Health Plan monitor length of stay to identify factors that might contribute to unnecessary hospital days.
  3. C
    The Optimum Health Group evaluates the medical necessity and appropriateness of proposed services and intervenes, if necessary, to redirect care to a more appropriate care setting.
  4. D
    The Axis Medical Group examines provider practice patterns to identify areas in which services are being underused, overused, or misused and designs strategies to prevent inappropriate utilization in the future.

Correct Answer:
D

Question #46
Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Whenever Mr. Murray receives a health claim from a plan member, he reviews the claim
  1. A
    A, B, C, and D
  2. B
    A and C only
  3. C
    A, B, and D only
  4. D
    B, C, and D only

Correct Answer:
A

Question #47
Ed O'Brien has both Medicare Part A and Part B coverage. He also has coverage under a PBM plan that uses a closed formulary to manage the cost and use of pharmaceuticals. Recently, Mr. O'Brien was hospitalized for an aneurysm. Later, he was transferred by:
  1. A
    Confinement in the extended-care facility after his hospitalization.
  2. B
    Transportation by ambulance from the hospital to the extended-care facility.
  3. C
    Physicians' professional services while he was hospitalized.
  4. D
    physicians' professional services while he was at the extended-care facility.

Correct Answer:
A

Question #48
Eleanor Giambi is covered by a typical 24-hour managed care program. One characteristic of this program is that it:
  1. A
    Provides Ms. Giambi with healthcare coverage for any illness or injury, but only if the cause of the illness or injury is work-related.
  2. B
    Combines the group health plan and disability plan offered by Ms. Giambi's employer with workers' compensation coverage.
  3. C
    Requires Ms. Giambi and her employer to each pay half of the cost of this coverage.
  4. D
    Requires Ms. Giambi to pay specified deductibles and copayments before receiving benefits under this program for any illness or injury.

Correct Answer:
B

Question #49
Emily Brown works for Integral Health Plan and represents the company as a board member for the board of directors. Which best describes Emily's position?
  1. A
    Community Representative
  2. B
    Inside Director
  3. C
    Outside Director
  4. D
    None of these

Correct Answer:
B

Question #50
Employer-sponsored benefit plans that provide healthcare benefits must comply with the Employee Retirement Income Security Act (ERISA). One of the most significant features of ERISA is that it:
  1. A
    contains a provision stating that the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plans
  2. B
    standardizes the conversion of group healthcare benefits to individual healthcare benefits
  3. C
    mandates that self-funded healthcare plans must pay state premium taxes
  4. D
    requires that all active employees, regardless of age, must be eligible for coverage under employer-sponsored benefit plans

Correct Answer:
A

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