AHIP AHM-530 Exam Practice Test Instant Access

Question 1

The Medicaid program subsidizes indigent care through payments to disproportionate share hospitals (DSHs). The Preamble Hospital is a DSH. As a DSH, Preamble most likely:

AReceives financial assistance from the federal government but not a state government.

BIs at a higher risk of operating at a loss than are most other hospitals.

CReceives no payments directly from Medicaid for services rendered but rather receives a portion of the capitation payment that Medicaid makes to the health plans with which Preamble contracts.

DIs eligible for capitation rates that are significantly higher than the FFS average for all covered Medicaid services.

Answer : B

Question 2

The following statements are about fee-for-service (FFS) payment systems. Select the answer choice containing the correct statement:

AA discounted fee-for-service (DFFS) system is usually easier for a health plan to administer than is a fee schedule system.

BA case rate payment system offers providers an incentive to take an active role in managing cost and utilization.

COne reason that health plans use a relative value scale (RVS) payment system is that RVS values for cognitive services have traditionally been higher than the values for procedural services.

DOne reason that health plans use a resource-based relative value scale (RBRVS) is that this system includes weighted unit values for all types of procedures.

Answer : B

Question 3

Dr. Leona Koenig removed the appendix of a plan member of the Helium health plan. In order to increase the level of reimbursement that she would receive from Helium, Dr. Koenig submitted to the health plan separate charges for the preoperative physical examination, the surgical procedure, and postoperative care. All of these charges should have been included in the code for the surgical procedure itself. Dr. Koenig's submission is a misuse of the coding system used by health plans and is an example of:

AUpcoding

BA wrap-around

CChurning

DUnbundling

Answer : D

Question 4

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.

During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.

The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan member for covered services is known as:

AAtermination with cause clause

BAhold-harmless clause

CAn indemnification clause

DAcorrective action clause

Answer : B

Question 5

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

Aprohibit 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

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

Cestablish 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

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

Answer : D

Question 6

The provider contracts that the Indigo Health Plan has with its providers include a clause which states that Indigo's denial of payment for a certain medical procedure does not constitute a medical opinion and is not intended to interfere with the provider-patient relationship. This information indicates that Indigo's provider contracts include:

AA business confidentiality clause.

BA scope of services clause.

CAn informed refusal clause.

DAn exculpation clause.

Answer : D

Question 7

One true statement about the responsibilities of providers under typical provider contracts is that most provider contracts:

Ainclude a clause which states that providers must maintain open communications with patients regarding appropriate treatment plans, unless the services are not covered by the member's health plan

Bhold that the responsibility of the provider to deliver services is usually subject to the provider's receipt of information regarding the eligibility of the member

Ccontain a gag clause or a gag rule

Dinclude a clause that explicitly places the responsibility for medical care on the health plan rather than on the provider of medical services

Answer : B

AHIP AHM-530 Network Management Exam Practice Test