ahm mocktest

8/12/2019 AHM Mocktest

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QALZ-AHM 2s0Duration: hourThis question aper contains 50 questionsDo not write or narh arything on the question paper and refitrn the paper when you leaveNo negative markingAll questions carry equal marks

All the Best

l. One ethical principle in managed care s the principle of non-maleficence, which holdsthat health plans and heir providers:

A. should allocate resources n a way that fairly distributes benefits and burdensamong he members

B. have a duty to present nformation honestly and are obligated to honorcommitnents

C. are obligated not to harm heir members

D. should treat each plan member n a manner hat respects his or her goals and values

2 Eleanor Giambi s covered by a typical 24-how managed are program. Onecharacteristic of this program is that it

A. provides Ms. Giambi with healthcare ovenrge or any llness or injury, but only ifthe cause of the illness or injury is work-related

B. combines he group health plan and disability plan offered by Ms. Giambi'semployer with workers' compensation overage

C. requires Ms. Giambi and her employer o each pay half of the cost of this coverage

D. requires Ms. Giambi to pay specified deductibles and copayments before receivingbenefits under his program for any llness or injury

3. In the United States, he Department of Defense offers ongoing healthcare coverage omilitary personnel and heir families ttuough the TRICARE health plan. One rue statement'about TRICARE is that

A. active duty military personnel re automatically onsidered nrolled n TRICAREPrime

B. TRIC{RE covers npatient and outpatient ervices, hysician and hospital charges,and rfdical supplies, but not mental health services


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A.

B.

$1,750

$1,800c. $2,000

D.52,25A

7- PhillipTsai s insured y both a traditional ndemnity ealth nsurance lan, which s hisPrimary lan, and a health plan, which s his secondary lan.Bothplanshave toi."fcoordination f benefits COB) provisions, ut neithei has a nonduplication fGnefitsprovision.Mr. Tsai ncurred 1,00O f medical xpenses rom a specialist ndassigned-b"nt s to the specialist, lro iledclaimswith bothplans. heeaditional tanpaiiatotalbenefitamount of $600 and notified hehealthptan of ttris payment.

ftr fri"f6 pi-determined hat, f it haf beel Mr. Tsai's rimaryplan, t *bufa have paidu Uerriniamour,tof $900.According o the COBprovision, he otulu*or-t that he realtn lan owJ onthese medical expenses as:

A. S0

B. $300

c. $400

D. $900

8' Primary care case Tan]gers (PCCMs) provide case management ervices o eligibleMedicaid recipients. with regard o pccMs it is correct o sly that:

A' PCCMs 0ryically receive a case management ee, rather han reimbursement ormedical services on a FFS basis, or the services hey provide to Medicaidrecipients

B' all Medicaid recipients who live in rural areas must be given a choice of at leastfour pCCMs

C' PCCMs receive a case management ee in addition to reimbursement or medicalservices n a FFS basis.

D' PCCMs contacl directly with the ederal governrnent o provide case managementservices o Medicaid ecipients

9. Medicaret- Choice product options nclude:

/


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D. assume ull responsibility for determinirig the claim payment proceduies or the

plan15. The NAIC adopted he HMO Model Act in order to provide a syslem of ongoingregulatory monitoring of HMOs. All of the following statements re conect about theHMO Model Act EXCEPT hat it:

A. regulates HMO operations n two critical arcas: inancial responsibility andhealthcare delivery

B. requires each HMO to send state egulators an annual report describing he HMO'sfinances and operations

C. focuses on three key aspects of healthcare delivery: network adequacy, qualityassufttnce, nd grievance procedures

D. requires state nsurance departrnents o conduct annual examinations of an HMO'soperations, quality assurance rograms, and provider networks

16. f a state commissioner of insurance places an HMO under adminisuative supervision,then he purpose f this action most likely is lo:

A. transfer all of the HMO's business o other carriers

B. allow the state commissioner, cting or a state court, o take contol of andadminister he HMO's assets and iabilities

C. sell the HMO's assets n order to satisfu he HMO's obligations

D. place he HMO's opemtions under he direction and conhol of the statecommissioner or.a person appointed by the commissioner

17. One ue statement bout Hill's COA is that

A- Hill had o have an nitial net worth of at least $1.5 million in order o obtain a COA

B. the COA most likely exempts Hill from any of State X's enabling statutes

C. Hill had o be organized as a partnership n order to obtain a COA

D. the COA in no way indicates hat Hill has demonstrated hat it is fiscally sound

18. The follgving statement(s) an correctly be made about he characteristics f a tlpicalHMO: ,

l. For delivering healthcare o its members, n HMO usually receives ompensationunder a retrospective eimbursement system.


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2. In order to provide its members with the maximum amount of convenience whenreceiving ancillary services, an HMO typically contracts with as many ancillary serviceproviders as possible.

3. An HMO arftnges for lhe delivery of medical care and provides, or shares nproviding,the inancing for that medical care.

A . l , 2 , a n d 3

B- I and2only

C. 2 an d 3 o n ly

D. 3 only

19.The Libra Health Plan s a closed-panel MO. This information most ikely ndicatesthat Libra's healthcare roviders

A. contact independently with Libra and can oin the HMO network as ong as theymeet Libra's standards f care

B. are either employees of Libra or belong o a group that confiacts with Libra

C. operate ut of their individual oflices

D. treat both Libra plan members and individuals who are not members of an HMO

20.In the erm'lPA model HMO,'what does PA stand or?

A. Independent ractitionerAssociation

B. Independent Practice Association

C. Internist Practice Association

D. Independent racticeAssessment

21. Paul Gilbert has been covercd by a group health plan for two years. He has been

uodergoing beatnent for angina or tbe past hree months. Iast week" Mi. Gilbert began anew ob and mmediately enrolled n his new company's goup health plaq wtrich has aone-year pre-existing condition provision. According to tbe Health lnsurance Portabilityand Accountability Act (tfIPAA) of 1996, he new health plan:

A. can exclude coverage or treatment of IVfr.Gilbert's angina for one year, becauseHIPAA does not impact a group health plan's pre-existing condition provision

.?t


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'B' can excludefverage ftirteatment of I\rIr.Girbert's irgou or one yea1, ecauser' Gilbert

did not have at east 36 montbs or"r"aituute coverage nderhisrevious ealth lan

c. canexcrude overage or teatnent of r&.'Girb"rt,, angina or three months,because hatls the ength of tirne he eceived r"**, for this mdical conditionrior o his enrollm"nt n rbenew healthd;---_-

D' cannot xcrude is angina sa pf-e.xfsting condition, because he one_yearpre_xisting ondition rovision s orset uy"ir*r, """'y"",

of"o.,tinuous orr"ragender is previous eatthplan

22-t},e ollowingstatementsreabout ederal aws hat affecthealthcare rganizations.elect he answerchoice ontaining il;il;;":

A' The women's ealthand canceS.Rights ct (wHcRA) of lggg requires ealthlans o offermastectomy benefits

B. The Hearth are e,uarity mprovement ct (HCelA).requiles hospitars, roupractices' ndHMos t'ocomply with all rtuia*i*titmst legislation, ven fhese ntities dhere o due pruo, srandards Jt are outrined n HceIA.c. The Newborns'and others'Hsarth rotectionAct (NMHpA)of 1996mandates hatcoverage or hospitar "y;;ffir}uirr,;;

;";;tiu" "inimum f24 hourcfor normar dir;;;tfi hours or cesarean irths.D' Although heMentar Hearth ,Tg-o:, (MH'A) does ot require trearth rans offermental ealth coverage' t imposes equirements n those plans hat doffermental ealth benefit .

-

23'In 1999' he ululed S-tates ongrery-passed he Financiar ervices Modemization ct,eferred o as he Gramm-Leach-Btii;vrcrnlagr n;;;"*rprovisions included nderhe GLB Act require inancial *i*;ioi,i..iyruaiic-od* fi*, to take severar teps orotect he privacy ofpersonal "f;;;". on" or"n.r, J"ir i, that inancial nstitutionsust: q.vev DrePo

A' notifrcustomeNojany.sharing fnon-public ersonar inancial nfonnationwithon-affiiated hjrdparties

" $*|}H:TtrffA::#,the pportunityobpt_out,ofharingon-public

c' ajsclole o affiriates, ut not o third.psr, theirprivacyporicies egarding heharin[of nonpublic ersonal nanciaf nformation


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29. Employers n a certain city have he following HMO options for providing gouP health

coverage or their emPloYees:

withinits geogmphic service are4 the sycamore HMO_, ll oPen-panel lan, hasconmcts witftLvetaf goup practicris of physicians and several specialty groups.physicians n the group pta"ti""s provide medical services o members of Sycamore

and to non'members.Physicians n the Elm HMO's panel of,provld9rs work in an ambulatory are

aiinty (ACF) and are salaried employees f &e plan'

From the answer choices below, select he responsi: hat conectly indicates he types of

HMO models represented y Sycamore and Elm.

A. Sycamore captive gouPElm= staff

Sycamore: networkElm = group

Sycamore: networkElm = staff

D. Sycamore: staffElm =network

30 .One qryical characteristic of prefened provider organization @PO) benefit plans is that

PPOs:

A. assume ull financial risk for arranging medical services or their members

B. require plan membirs to obtain a referral before getting medical services romspecialists

C. use a capitation arrangement, nstead of a fee schedule, o reimburse physicians

D. offer some coverage, althougb at a higher cos for plan members urho choose o use

the services of non-network providen

3l.How do PPOs usually pay physicians?

Salary

Fee-for-service

Capitation

Fee cap or maximum allowable eeI

B.

c.

A.

B.

C.

D.


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i3oy"nof the choices ilow is the characteristic fariEpo thatdistinguishes t froina

A. Administation

B. Structure

C . O p e r a t i o n s , ,,

' 1 - '

D. Out-of-network care

33' TheArgyleHeatth lanhasestablishedpicalcomplaint esolution rocedurescRps)omanage isnutel,lth members.-Argylr#t""eiuJi r",,'r one appeal romNicoleenoit, nArgvre l.tg:-u"r. arso,"Lg{g has ;;;;;iration withano&erpranember,eterendl.with egardihd diqput"i-iii.oJtik;ft;;;il *i *"r,

A' bothM* Benoitand v1r. endl are prevented yArgyle,scRps from beingpresenthen heir cases re heard nd rom presenting h;;;"np*ctivesb' only he decisionmade on Mr. Lendt's ase s a finar,binding ecisionc' onlyMs' Benoit's ppear s an exampre f an nformar ppearD' only Ms. Benoit's ppearwit be heard yan mpartiar

hirdparty34' The Manor HeatthPIan uses nautomated ystem hat answers elephone alls withecorded rsynthesized pegch naprompt, he carier J,..rpo"a ," a _enu of options bynteringnformationttougn","*f.r"GilrJil;;ffihg into hephone.

Eachresponse akes he caller o the next

"pp-pri"t *"rru',rlriit cailer eceives hedesirednformation rom thl system, angs i]oiselects theopion tJ speak o a representative.he squire HealthPlan uJs u *i", td;;; ,"r"orr*. carts with a recordedessase nd hen outes ars to th9approp.1ilil;;iT*, at squire. Ifnoepresentative n the appropriate it i, uuuil{L;4 , ;;,i;;aces the cail in a queue oeanswered hen a representative ecomes vailable.

fi;[f'"*ng

statement(9 an o".,ryi. made bout he echnorogy sedby Manor and

A- Manor's ystem s best described san automated aildistributor ACD).t

*?S}fflilii.""tandSqutue'sevice reapplicationsfcomputer/terephone

c. srfre's device s best described.as n nteractive oice esponse IVR) system.D. All of these statemenb re correct.


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35. Katrina LnWz is a claims analyst or a health plan plan hat provides a higher evel ofbenefits for services received n-network than for services eceived out-of-neivork. Ms.I.oWz reviewed a health clarm for answers

o thefollowing questions:

Question A - was the provider a participant in the plan's network?Question B - Does he member have other healthcare coverage?Question C - Is the premium paid or not?Question D - What benefits are payable?

If this was Abpical claim, then Ms. Lr:irrlrwas correct to seek answers o questions:

A. A, B, C, and D

B. A, B, and D only

C. B, C, and D only

D. AandConly

36 The Mosaic heatth plan uses a typical elecfonic medical ecord (ElvfR) to document hemedical care ts members eceive. One characteristic of Mosaic's EMR is that it:

A. does not provide any clinical decision support or Mosaic's providers

B- is designed o supply information at the site of care

C. contains a Mosaic member,s linical data only

D. is organized by the type of treatnent or by provider

l] I: address he problems associated with multiple data management ystems, he KayakHealth Plan has begun o use a data warehouse One likely charlteristic of Kayaks datawarehouse s that

A. it requires Kayak's individual databases o store arge amounts of data that are notneeded or daily operations

B. it contains data frsm internal sources only

C. it stores historicat data rather than current data

D- the data n the warehouse are linked by a common subject

3E-Th9l----------------*ompany was interested npurchasing PPO coverage or its 90 employees andasked Hill to determine a premium rate for the coverage. Hill would administe; the planand guaranteeclaim payments by panng all incurred Lvered benefits, and Jet would makemonthly O*Tu* payments o Hill for the PPO coverage. Because Jet had been covered


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' t b l r . l - r : o s t - o

A. Advertising, ersonal elling, sales romotion, nd publicity

B. Advertising, ribe, sates romotion,and publicity

C. Admissions, ersonal elling,sales romotion, nd publicity

D. Advertising personal elling, sales romotion, ndprivacy

42.TbE main purpose f the Health PIan Employer Dataand nforrnation Set HEDIS) s toprovide

A. expert consultation o end-users or solving speciatized nd complex healthc.areproblems tuough he use of a knowledge-based omputer system

B. a mathematical model that can predict uture conditions or eyents n the healthcareindustry

C- measurements f plan performance ndeffectiveness hat potential healthcarepurchasers an use o compare he quality offered by different healthcare lans

D. a comprehensive ccreditation or PPOs

43. One characteristic f the accreditation rocess or health lans s that his process:

A. is voluntary or health plans-

B. requircs all change ccrcditation organizations o use he same landards faccreditation

C. typically requires he accrediting organization o conduct a medical ecord eviewand a review of a hbalth plan's credentialing rocesses, ut not an evaluation f thehealth lans'member ervice ystems rocesses

D. cannot assure hat a health plan meets a specified evel of quality

44. As pa* of its quallty management rogram, he Lyric Health Plan egularly compares

its practices and senices withthose of its most successful ompetitor. When Lyricconcludes hat ts competito/s practices or services are better han its own, Lyricimplements he changes ecessary o achieve overall qualit), mprovement. Thisinformation ndicates hat Lyric assesses ts performance y using a method known as:

A. benchmarking

B. standard f care

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C. an adverse verit

D. case-mixadjustnent45' which of the oltowing s the bestdescription f what a ?rocess neasure, varuates?

A. The natu:member::;'xHr.$T;**,Tl? ofthe esourceshat hearthpranas vairabreor

tff#ods

andprocedtuesahealth lanand ts providers se o furnish erviceC- The extent o which services succeeJ n i--_ .;_^

patient health.-'tcceed n improving

or maintaining satisfaction and

46' The data evaluation stage f utilization:"]"y (uR) inctudes both administrativeeviewsndmedicarui"rir.6rrlr#'*,emenr abouthese pes freviewss hat:^*:m:#:'#fr'"* must e onductedya hearth tan taffmemberwho s a

B. the prinrary$rno1e of an administrativereview s tof a proposed

medical "JJ*"q4uvtirevlew s to evaluate

he appropriatenessc' uR staffmem ,ers picarty cond,ucl medicar eviewof a proposed medicarervicebefore rey conauci

"a.r,t"*irir.i"Tr", that same ervice

" a"alffi;::amedicar eview s to evaruate he medical ecessity f a proposed

ffilillffii#,"#;f:#rTffi.#J,:;ffffiffi3:fftffi;A' requirementthat Ms. Garcia's hysiciannotis the planprior to her hospital izationt

;*if;TJ$l| ]#f stav Los)estirnatesnd ischargeranningorMs.

l'*rtent of a uM nurse omonitorMs-Garcia's are uring erhospitalizationp' revrw' after Ms' Garcia is discharged, of the entire b'r for her hospitarization


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A. 67

B. 274

c. 365

48. n order o help review s institutional utilizationates' he Sahalee Medical Group' a

heatth plan, uses r," ,t-i*a formula t" #;ltttnotpitalbed days per l'000 plan

members or the torr',ilJ au'" f*tm) Ott eptit20' dahalee ;e0 *ie following

information o calculate ospitalbed daysper_1,000 embers or thqMTD:

Plan membership .. . "' " "' -" "" """ """"20'000

i;;;;; t"spitalbeddavsn MrD ""-""300This nformutionnoiiJtJir,ulon Aprilzo,'3rrt"r*s

numberof eddays er '000plan

;;;tt for the month to date was approximately:

,r. ilJff:* plans renow ntegrating iqease anagementnto heirmedical

management rogrur*]O""-"t -u"ietistic ofdisease management s that t

A.tendstokmoreappropriateforheatingmedjcalconditionsthathavemanycomplications *t ii,ilcannot U"pr"t"ntfu rather

han condi{ions hat have a high

rate bf preventable omplications

B. standardizes are as much as possiblcto ensruehat all phypicians n the program

provide tr," ,uiJ ;; ;i"*; * d;.;;;hyri"i-twlo-rloutinelv achieve he best

outcomes

c. focuses on individual episodes of medical caretrther han on the comprehensive

care of the Patient over time

D. focuses on treating medical conditions hat showa l9w rategf variabilily in pattems

of heatrnent lo*?u,i"n to patient and from physiciano physician

50. Provider ntegration has wo components: perationalntegration and structural

integrarion. A" *"-;i; ;#;ilr,a itrt"gution inhealth plans s the:

A.acquisitionoftheLeopardHealthPlanbytheHickoryHealttrPlan

B. joint venture enterd nto by the Eclipse Healrh.Plannd e local hospital system o

create a new health plan in *rri"r, rr'ripr. -4,n" hospitalsystem share ownership

C.forurationofanorganizationbyagroupgfnrlvrr\ntocapryoutbilling''.coltections,ffi;;ilffiil',h f,Jtti plans or heentire ouP

ofproviders

D. consolidation f the carver Health Plan and he LimestoneHealth Plan

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