AHIP AHM-510 - Governance and Regulation Exam
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Total 76 questions
Question #6 (Topic: )
Arthur Dace, a plan member of the Bloom Health Plan, tried repeatedly over an extended
period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr.
Dace informally surveyed other Bloom plan members and found that many people were
experiencing similar problems getting an appointment with this particular provider. Mr.
Dace threatened to take legal action against Bloom, alleging that the health plan had
deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making
it difficult for patients to make appointments with Dr. Pyle.
Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR)
method that is quicker and less expensive than litigation. Under this ADR method, both
Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who
issued a decision that Bloom's utilization management practices in this case did not
constitute a form of abuse. The panel's decision is legally binding on both parties.
This information indicates that Bloom resolved its dispute with Mr. Dace by using an ADR
method known as:
period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr.
Dace informally surveyed other Bloom plan members and found that many people were
experiencing similar problems getting an appointment with this particular provider. Mr.
Dace threatened to take legal action against Bloom, alleging that the health plan had
deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making
it difficult for patients to make appointments with Dr. Pyle.
Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR)
method that is quicker and less expensive than litigation. Under this ADR method, both
Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who
issued a decision that Bloom's utilization management practices in this case did not
constitute a form of abuse. The panel's decision is legally binding on both parties.
This information indicates that Bloom resolved its dispute with Mr. Dace by using an ADR
method known as:
A. Corporate risk management
B. An ombudsman program
C. An ethics committee
D. Arbitration
Answer: D
Question #7 (Topic: )
Determine whether the following statement is true or false:
Failing to adopt and implement standards for the prompt investigation and settlement of
claims is an example of an activity that would be considered an improper claims practice
according to the NAIC Model Unfair Claims Settlement Practices Act.
Failing to adopt and implement standards for the prompt investigation and settlement of
claims is an example of an activity that would be considered an improper claims practice
according to the NAIC Model Unfair Claims Settlement Practices Act.
A. True
B. False
Answer: A
Question #8 (Topic: )
In the paragraph below, a statement contains two pairs of terms enclosed in parentheses.
Determine which term in each pair correctly completes the statement. Then select the
answer choice containing the two terms that you have chosen.
One type of acquisition is called a stock purchase. In a typical stock purchase, a company
acquires (51% / 100%) of the voting shares of another company's stock, thereby making
the acquired company a subsidiary. The (acquired / acquiring) company holds all of the
assets and liabilities of the acquired company.
Determine which term in each pair correctly completes the statement. Then select the
answer choice containing the two terms that you have chosen.
One type of acquisition is called a stock purchase. In a typical stock purchase, a company
acquires (51% / 100%) of the voting shares of another company's stock, thereby making
the acquired company a subsidiary. The (acquired / acquiring) company holds all of the
assets and liabilities of the acquired company.
A. 51% / acquired
B. 51% / acquiring
C. 100% / acquired
D. 100% / acquiring
Answer: C
Question #9 (Topic: )
Arthur Dace, a plan member of the Bloom health plan, tried repeatedly over an extended
period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr.
Dace informally surveyed other Bloom plan members and found that many people were
experiencing similar problems getting an appointment with this particular provider. Mr.
Dace threatened to take legal action against Bloom, alleging that the health plan had
deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making
it difficult for patients to make appointments with Dr. Pyle.
Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR)
method that is quicker and less expensive than litigation. Under this ADR method, both
Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who
issued a decision that Bloom's utilization management practices in this case did not
constitute a form of abuse. The panel's decision is legally binding on both parties.
Different types of compensation arrangements in managed care plans, from fee-for-service
(FFS) arrangements to capitation arrangements, lead to different types of fraud and abuse.
From the answer choices below, select the response that identifies the form of abuse in
which Bloom is allegedly engaging, according to Mr. Dace's complaint, and whether this
form of abuse is more likely to occur in FFS compensation arrangements or in capitation
arrangements.
period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr.
Dace informally surveyed other Bloom plan members and found that many people were
experiencing similar problems getting an appointment with this particular provider. Mr.
Dace threatened to take legal action against Bloom, alleging that the health plan had
deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making
it difficult for patients to make appointments with Dr. Pyle.
Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR)
method that is quicker and less expensive than litigation. Under this ADR method, both
Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who
issued a decision that Bloom's utilization management practices in this case did not
constitute a form of abuse. The panel's decision is legally binding on both parties.
Different types of compensation arrangements in managed care plans, from fee-for-service
(FFS) arrangements to capitation arrangements, lead to different types of fraud and abuse.
From the answer choices below, select the response that identifies the form of abuse in
which Bloom is allegedly engaging, according to Mr. Dace's complaint, and whether this
form of abuse is more likely to occur in FFS compensation arrangements or in capitation
arrangements.
A. Type of abuse underutilization Type of compensation arrangement FFS arrangement
B. Type of abuse underutilization Type of compensation arrangement capitation arrangement
C. Type of abuse overutilization Type of compensation arrangement FFS arrangement
D. Type of abuse overutilization Type of compensation arrangement capitation arrangement
Answer: B
Question #10 (Topic: )
The Department of Health and Human Services (HHS) has delegated its responsibility for
development and oversight of regulations under the Health Insurance Portability and
Accountability Act (HIPAA) to an office within the Centers for Medicaid & Medicare
Services (CMS). The CMS office that is responsible for enforcing the federal requirements
of HIPAA is the
development and oversight of regulations under the Health Insurance Portability and
Accountability Act (HIPAA) to an office within the Centers for Medicaid & Medicare
Services (CMS). The CMS office that is responsible for enforcing the federal requirements
of HIPAA is the
A. Center for Health Plans and Providers (CHPPs)
B. Center for Medicaid and State Operations
C. Center for Beneficiary Services
D. Center for Managed Care
Answer: B
