Healthcare Management: An Introduction v4.0 (AHM-250)

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Total 372 questions

If left unresolved, member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info

  • A. A Level One appeal, and the member has the right to a further appeal
  • B. A Level Two appeal, and the reviewer's decision is final and binding
  • C. An independent external appeal, and the member has the right to a further appeal
  • D. Arbitration, and the reviewer's decision is final and binding


Answer : A

Historically most HMOs have been

  • A. Closed-access HMO
  • B. Closed-panel HMO
  • C. Open-access HMO
  • D. Open-panel HMO


Answer : B

Eleanor Giambi is covered by a typical 24-hour managed care program. One characteristic of this program is that it:

  • 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.
  • B. Combines the group health plan and disability plan offered by Ms. Giambi's employer with workers' compensation coverage.
  • C. Requires Ms. Giambi and her employer to each pay half of the cost of this coverage.
  • D. Requires Ms. Giambi to pay specified deductibles and copayments before receiving benefits under this program for any illness or injury.


Answer : B

In order to measure the expenses of institutional utilization, Holt Healthcare Group uses the standard formula to calculate hospital bed days per 1,000 plan members per year. On
October 23, Holt used the following information to calculate the bed days per

  • A. 278
  • B. 397
  • C. 403
  • D. 920


Answer : B

In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of

  • A. Prospective review
  • B. Concurrent review
  • C.
  • D. A, B, and C
  • E. A and B only
  • F. A and C only
  • G. B only


Answer : D

As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members:
-> Brad Van Note, age 28, is taking many different, costly medications for

  • A. Mr. Van Note, Mr. Albrecht, and Ms. Cromartie
  • B. Mr. Van Note and Ms. Cromartie only
  • C. Mr. Van Note and Mr. Albrecht only
  • D. Mr. Albrecht and Ms. Cromartie only


Answer : C

An exclusive provider organization (EPO) operates much like a PPO. However, one difference between an EPO and a PPO is that an EPO

  • A. Is regulated under federal HMO legislation
  • B. Generally provides no benefits for out-of-network care
  • C. Has no provider network of physicians
  • D. Is not subject to state insurance laws


Answer : B

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 billi

  • 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
  • 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
  • C. prevent Dr. Ware from seeking compensation from patients if Riverside fails to compensate him because of the MCO's insolvency
  • D. prevent Dr. Ware from billing a Riverside member for medical services that are not included in Riverside's plan


Answer : B

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, fo

  • A. the angina, the high blood pressure, and the broken ankle
  • B. the angina and the high blood pressure only
  • C. none of these conditions
  • D. the broken ankle only


Answer : A

A medical foundation is a not-for-profit entity that purchases and manages physician practices. In order to retain its not-for-profit status, a medical foundation must

  • A. Provide significant benefit to the community
  • B. Employ, rather than contract with, participating physicians
  • C. Achieve economies of scale through facility consolidation and practice management
  • D. Refrain from the corporate practice of medicine


Answer : A

Amendments to the HMO act 1973 do not permit federally qualified HMO’s to use

  • A. Retrospective experience rating
  • B. Adjusted community rating
  • C. Community rating by class
  • D. Community rating


Answer : A

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:

  • A. State that Dr. Aldridge's provider contract with Badger will automatically terminate if he loses his medical license or hospital privileges.
  • 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.
  • C. Give Dr. Aldridge the right to appeal Badger's decision if he is terminated with cause from Badger's provider network.
  • 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.


Answer : C

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?

  • A. Community Representative
  • B. Inside Director
  • C. Outside Director
  • D. None of these


Answer : B

In assessing the potential degree of risk represented by a proposed insured, a health underwriter considers the factor of anti selection. Anti selection can correctly be defined as the

  • A. inability of a proposed insured to share with the insurer the financial risks of healthcare coverage
  • B. possibility that a proposed insured will profit from an illness by receiving benefits that exceed the total amount of his or her eligible medical expenses
  • C. inability of a proposed insured to provide sufficient evidence that proves he or she is an insurable risk
  • D. tendency of people who have a greater-than-average likelihood of loss to apply for or continue insurance protection to a greater extent than people who have an average or less than average likelihood of the same loss


Answer : D

A particular health plan offers a higher level of benefits for services provided in-network than for out-of-network services. This health plan requires preauthorization for certain medical services.
With regard to the steps that the health plan's claims e

  • A. should assume that all services requiring preauthorization have been preauthorized
  • B. should investigate any conflicts between diagnostic codes and treatment codes before approving the claim to ensure that the appropriate payment is made for the claim
  • C. need not verify that the provider is part of the health plan's network before approving the claim at the in-network level of benefits
  • D. need not determine whether the member is covered by another health plan that allows for coordination of benefits


Answer : B

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Total 372 questions