Network Management (AHM-530) Free Practice Test

Question 1

Health plans typically conduct two types of reviews of a provider's medical records: an evaluation of the provider's medical record keeping (MRK) practices and a medical record review (MRR). One true statement about these types of reviews is that:

A. An MRR includes a review of the policies, procedures, and documentation standards the provider follows to create and maintain medical records.

B. The NCQA requires an examination of MRK with all of a health plan's office evaluations.

C. An MRK covers the content of specific patient records of a provider.

D. The NCQA requires MRR for both credentialing and recredentialing of providers in a health plan's network.

Correct Answer: C

Question 2

The Foxfire Health Plan, which has 20,000 members, contracts with dermatologists on a contact capitation basis. The contact capitation arrangement has the following features:
Foxfire distributes the money in the contact capitation fund once each quarter and the distribution is based on the point totals accumulated by each dermatologist.
Foxfire's per member per month (PMPM) capitation for dermatology services is $1.
The dermatologist receives 1 point for each new referral that is not classified as a complicated referral and 1.5 points for each new referral that is classified as complicated.
During the first quarter, Foxfire's PCPs made 450 referrals to dermatologists and 100 of these referrals were classified as complicated. One dermatologist, Dr. Shareef Rashad, received 42 of these referrals; 6 of his referrals were classified as complicated. Statements that can correctly be made about Foxfire's contact capitation arrangement include:

A. that the payment that Foxfire owed Dr. Rashad for the first quarter was $6,120

B. that the value of each referral point for the first quarter was $120

C. that the value of Foxfire's contact capitation fund for dermatologists for the first quarter was $20,000

D. all of the above

Correct Answer: B

Question 3

Health plans use a variety of sources to find candidates to recruit for their provider networks. In general, two of the most effective methods of finding candidates are through

A. Word of mouth and on-site training programs

B. Advertisements in local newspapers and on-site training programs

C. Word of mouth and direct mail

D. Advertisements in local newspapers and direct mail

Correct Answer: C

Question 4

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.
Autumn's method of reimbursing specialty providers can best be described as a

A. Withhold arrangement

B. Disease-specific arrangement

C. Risk adjustment arrangement

D. Contact capitation arrangement

Correct Answer: D

Question 5

Promise, Inc., a corporation that specializes in cancer services, employs its physicians and support staff and provides facilities and ancillary services for cancer patients. Promise has contracted with the Cordelia Health Plan to provide all specialty services for Cordelia plan members who are undergoing cancer treatment. In return, Promise receives a capitated amount from Cordelia. Promise is an example of a type of specialty services organization known as a

A. Disease management company

B. Specialty network management company

C. Single specialty management specialist

D. Specialty IPA

Correct Answer: A

Question 6

The actual number of providers included in a provider network can be based on staffing ratios. One true statement about staffing ratios is that, typically:

A. Physician-to-enrollee ratios can be used directly only by network-within-a-network model HMOs.

B. A small health plan needs fewer physicians per 1,000 than does a large plan.

C. A closely managed health plan requires fewer providers than does a loosely managed plan.

D. Medicare products require fewer providers than do employer-sponsored plans of the same size.

Correct Answer: C

Question 7

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. Neither A nor B

B. Both A and B

C. A only

D. 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.

E. B only

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

Correct Answer: F

Question 8

With regard to the compensation of dental care providers in a managed dental care system, it is correct to state that, typically:

A. dental PPOs compensate dentists on a capitated basis

B. independent practice association (IPA)-model dental HMOs (DHMOs) capitate general dental practitioners

C. group model dental HMOs (DHMOs) compensate general dental practitioners on a salaried basis

D. staff model dental HMOs (DHMOs) compensate dentists on an FFS basis

Correct Answer: B

Question 9

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.
The network strategy that Gardenia is using to establish its range of healthcare plans is known as the

A. network-within-a-network approach

B. gatekeeper approach

C. preferred tier approach

D. tiered network approach

Correct Answer: A

Question 10

Health plans are required to follow several regulations and guidelines regarding the access and adequacy of their provider networks. The Federal Employee Health Benefits Program (FEHBP) regulations, for example, require that health plans

A. Provide access to Title X family-planning clinics

B. Allow members direct access to OB/GYN services

C. Allow members direct access to prescription drug services

D. Provide average office waiting times of no more than 30 minutes for appointments with plan providers

Correct Answer: D

Question 11

The Holiday Health Plan is preparing to enter a new market. In order to determine the optimal size of its provider panel in the new market, Holiday is conducting a competitive analysis of provider networks of the market's existing health plans. Consider whether, in conducting its competitive analysis, Holiday should seek answers to the following questions:
Question 1
: What are the cost-containment strategies of the health plans with increasing market shares?
Question 2
: What are the premium strategies of the health plans with large market shares?
Question 3
: What are the characteristics of health plans that are losing market share?
In its competitive analysis, Holiday should most likely obtain answers to questions

A. 1, 2, and 3

B. 1 and 2 only

C. 1 and 3 only

D. 2 and 3 only

Correct Answer: A

Question 12

During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider's application. One true statement regarding this process is that the health plan

A. has a legal right to access a prospective provider's confidential medical records at any time

B. must limit any evaluations of a prospective provider's office to an assessment of quantitative factors, such as the number of double-booked appointments a physicianaccepts at the end of each day

C. is prohibited by law from conducting primary verification of such data as a prospective provider's scope of medical malpractice insurance coverage and federal tax identification number

D. must complete the credentialing process before a provider signs the network contract or must include in the signed document a provision that the final contract is contingent upon the completion of the credentialing process

Correct Answer: D

Question 13

The provider contract that Dr. Bijay Patel has with the Arbor Health Plan includes a no-balance-billing clause. The purpose of this clause is to:

A. allow Dr. Patel to bill patients for services only if the services are considered to be medically necessary

B. require Dr. Patel to accept Arbor's payment as payment in full for medical services that he provides to Arbor plan members

C. establish the guidelines used to determine if Arbor is the primary payor of benefits in a situation in which an Arbor plan member is covered by more than one health plan

D. prohibit Dr. Patel from collecting payments from Arbor plan members for medical services that he provided them, even if the services are explicitly excluded from the benefit plan

Correct Answer: B

Question 14

Lakesha Frazier, a member of a health plan in a rural area, had been experiencing heart palpitations and shortness of breath. Ms. Frazier's primary care provider (PCP) referred her to a local hospital for an electrocardiogram. The results of the electrocardiogram were transmitted for diagnosis via high-speed data transmission to a heart specialist in a city 500 miles away. This information indicates that the results of Ms. Frazier's electrocardiogram were transmitted using a communications system known as

A. Anarrow network

B. An integrated healthcare delivery system

C. Telemedicine

D. Customized networking

Correct Answer: C

Welcome to TestSimulate

AHIP Network Management (AHM-530) Free Practice Test