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  • Exam Name: Medical Management
  • Last Update: Jun 15, 2024
  • Questions and Answers: 163
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AHM-540 Practice Exam Questions with Answers Medical Management Certification

Question # 6

To improve members’ abilities to make appropriate care decisions about specific medical problems, some health plans use a form of decision support known as telephone triage programs. The following statements are about telephone triage programs. Select the answer choice containing the correct statement.

A.

The primary role of telephone triage clinical staff is to diagnose the caller’s condition and give medical advice.

B.

Quality management (QM) for telephone triage programs typically focuses on the clinical information provided rather than on the quality of service.

C.

Currently, none of the major accrediting agencies offers an accreditation program specifically for telephone triage programs.

D.

A telephone triage program may also include a self-care component.

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Question # 7

Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located at a military installation. Ms. Wilson serves as a primary point of contact between enrollees and the TRICARE system and answers enrollees’ questions about plan options, eligibility, provider selection, and claims. This information indicates that Ms. Wilson serves as a

A.

lead agent

B.

beneficiary services representative

C.

health plan support contractor

D.

primary care manager (PCM)

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Question # 8

State governments serve as both regulators and purchasers of health plan services. The influence of state governments as purchasers is focused on

A.

Medicare and TRICARE programs

B.

Medicaid and workers’ compensation programs

C.

Medicare and Medicaid programs

D.

TRICARE and workers’ compensation programs

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Question # 9

The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.

One component of UR is an administrative review. An administrative review compares the proposed medical care to the applicable (medical policy / contract provision). This type of review (can / cannot) be conducted by a nonclinical staff member.

A.

medical policy / can

B.

medical policy / cannot

C.

contract provision / can

D.

contract provision / cannot

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Question # 10

The Garnet Health Plan uses provider profiling to measure and improve provider performance. Provider profiling most likely allows Garnet to

A.

evaluate all providers without considering differences in risk

B.

focus on specific clinical decisions of Garnet’s providers rather than on patterns of care

C.

identify the outliers and high-value providers in its provider network

D.

measure the effectiveness, but not the efficiency, of Garnet’s providers

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Question # 11

The following statements are about risk management for case management. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A.

The use of a signed consent authorization form is consistent with accrediting agency standards for patient privacy and confidentiality of medical information.

B.

Case management that is initiated after a member has incurred substantial medical expenses is more likely to be viewed as a tool to cut costs rather than to improve outcomes.

C.

Health plan documents indicating that any case management delegates are separate, independent entities may reduce an health plan's exposure to risk.

D.

A case management file cannot be used to support the health plan's position in the event of a lawsuit.

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Question # 12

The Brighton Health Plan regularly performs prospective UR for surgical procedures. Brighton’s prospective UR activities are likely to include

A.

documenting the clinical details of the patient’s condition and care

B.

tracking the length of inpatient stay

C.

completing the discharge planning process

D.

determining the most appropriate setting for the proposed course of care

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Question # 13

Comparing the quality of managed Medicare programs with the quality of FFS Medicare programs is often difficult. Unlike FFS Medicare, managed Medicare programs

A.

can measure and report quality only at the provider level

B.

use a single system to deliver services to all plan members

C.

provide an organizational focus for accountability

D.

can use the same performance measures for all products and plans

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Question # 14

The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.

Due to competitive pressures and consumer demand, many health plans now offer direct access or open access products. Under a direct access product, a member is (required / not required) to select a primary care provider (PCP), and is (required / not required) to obtain a referral from a PCP or the health plan before visiting a network specialist.

A.

required / required

B.

required / not required

C.

not required / required

D.

not required / not required

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Question # 15

Health plans conduct evaluations on the efficiency and effectiveness of their quality improvement activities. With regard to the effectiveness of quality improvement plans, it is correct to say that

A.

effectiveness is the relationship between what the organization puts into an improvement plan and what it gets out of the plan

B.

effectiveness is measured by reviewing outcomes to determine the accuracy or appropriateness of the strategy and the adequacy of resources allocated to that strategy

C.

the effectiveness of an action plan is typically measured with a concurrent evaluation

D.

an evaluation of plan effectiveness produces one of two results: the plan either (a) achieved the desired outcomes or (b) did not achieve the desired outcomes and is unlikely to do so under current conditions

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Question # 16

The following statements are about QAPI as it applies to Medicare+Choice plans and Medicaid health plan entities. Select the answer choice containing the correct statement.

A.

QAPI provides separate sets of standards for Medicaid MCEs and Medicare+Choice plans.

B.

Medicaid primary care case management (PCCM) programs are required to comply with all QAPI standards.

C.

QISMC standards for quality measurement and improvement apply only to clinical services delivered to Medicare and Medicaid enrollees.

D.

States that require Medicaid MCEs to comply with QAPI standards are considered to be in compliance with CMS quality assessment and improvement regulations.

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Question # 17

All states have laws describing the conditions under which pharmacists can substitute a generic drug for a brand-name drug. With respect to these laws, it is correct to say that in every state,

A.

pharmacists must obtain physician approval before substituting generics for brand-name drugs

B.

pharmacists must obtain authorization from the health plan before substituting generics for brand-name drugs

C.

prescribers must obtain authorization from the health plan before prescribing a brand-name drug

D.

prescribers have some mechanism that allows them to prevent pharmacists from substituting generics for brand-name drugs

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Question # 18

The following statements are about the use of provider profiling for pharmacy benefits. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A.

Health plans typically use provider profiles to improve the quality of care associated with the use of prescription drugs.

B.

Provider profiles identify prescribing patterns that fall outside normal ranges.

C.

Health plans can motivate providers to change their prescribing patterns by sharing profile information with plan members and the general public.

D.

Provider profiles are effective in modifying individual prescribing patterns, but they have little effect on group prescribing patterns.

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Question # 19

Health plan performance measures include structure measures, process measures, and outcome measures. The following statements are about the characteristics of these three types of performance measures. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A.

The most widely used structure measures relate to physician education and training.

B.

One advantage of structure measures over process measures is that structures are often linked directly to healthcare outcomes.

C.

Process measures are useful in identifying underuse, overuse, and inappropriate use of services.

D.

One disadvantage of outcome measures is that they can be influenced by factors outside the control of the health plan.

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Question # 20

The following statements are about health plans' complaint resolution procedures (CRPs). Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A.

An health plan's CRPs reduce the likelihood of errors in decision making.

B.

CRPs typically provide for at least two levels of appeal for formal appeals.

C.

CRPs include only formal appeals and do not apply to informal complaints.

D.

Most complaints are resolved without proceeding through the entire CRP process.

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Question # 21

The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

Each quality standard used by a health plan is associated with quality indicators. A ______________ indicator is a form of aggregate data indicator that produces results that fit within a specified range, such as the length of time to schedule an appointment.

A.

yes/no

B.

sentinel event

C.

discrete variable

D.

continuous variable

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Question # 22

PBMs are accredited by the same organizations that accredit health plans.

A.

True

B.

False

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Question # 23

The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self-care most likely would not be appropriate.

A.

Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area.

B.

Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day.

C.

Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility.

D.

Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.

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Question # 24

With respect to the activities of MCO medical directors, it is correct to say that medical directors typically perform all of the following activities EXCEPT

A.

maintaining clinical practices

B.

delivering performance feedback to providers

C.

participating in utilization management (UM) activities

D.

educating other MCO staff about new clinical developments or provider innovations that might impact clinical practice management

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Question # 25

Benchmarking is a quality improvement strategy used by some health plans. With regard to benchmarking, it is correct to say that

A.

cost-based benchmarking reveals why some areas of a health plan perform better or worse than comparable areas of other organizations

B.

diagnosis-related groups (DRGs) are a source of benchmarking data that describe individual procedures and cover both inpatient and outpatient care

C.

patient billing records provide a much more accurate account of procedure costs for benchmarking than do current procedural terminology (CPT) codes

D.

the focus of benchmarking for health plan has shifted from identifying the lowest cost practices to identifying best practices

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Question # 26

A health plan's preventive care initiatives may be classified into three main categories: primary prevention, secondary prevention, and tertiary prevention. Secondary prevention refers to activities designed to

A.

develop an appropriate treatment strategy for patients whose conditions require extensive, complex healthcare

B.

educate and motivate members to prevent illness through their lifestyle choices

C.

prevent the occurrence of illness or injury

D.

detect a medical condition in its early stages and prevent or at least delay disease progression and complications

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Question # 27

The Midwest Health Plan delegated utilization review (UR) activities to the Tri-City Utilization Review Organization. After Tri-City improperly recommended denial of payment for services to a Midwest plan member, the plan member filed suit. The court ruled that Midwest was responsible for Tri-City’s actions because of the relationship between Midwest and Tri-City. This situation is an illustration of a legal concept known as

A.

vicarious liability

B.

fraud

C.

a tying arrangement

D.

subdelegation

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Question # 28

To measure performance for quality management, health plans collect and analyze three types of data: financial data, clinical data, and customer satisfaction data. The following statement(s) can correctly be made about the sources of clinical data:

1. Patient surveys are the most widely used source of disease-specific clinical information

2. Outcomes research studies sponsored by academic institutions and professional organizations have limited usefulness for particular health plans or individual providers

3. The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys address both physical and mental health status

A.

All of the above

B.

1 and 2 only

C.

2 and 3 only

D.

3 only

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Question # 29

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.

In most commercial health plans, the case management process is directed by a case manager whose responsibilities typically include

A.

focusing on a disabled member’s vocational rehabilitation and training

B.

approving all care decisions for patients under case management

C.

reducing the fragmentation of care that often results when individuals obtain services from several different providers

D.

all of the above

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Question # 30

Medicare beneficiaries can obtain healthcare benefits through fee-for-service (FFS) Medicare programs, Medicare medical savings account (MSA) plans, Medigap insurance, or coordinated care plans (CCPs). Unlike other coverage options, CCPs

A.

provide only those benefits covered by Medicare Part A and Part B

B.

are not subject to federal or state regulation

C.

place primary care at the center of the delivery system

D.

are structured as indemnity plans

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Question # 31

The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the two terms or phrases that you have selected.

The process for collecting and analyzing data differs for quality assessment (QA) and quality improvement (QI). For QA, data collection focuses on (objective / both objective and subjective) data, and data analysis identifies the (degree / cause) of variance.

A.

objective / degree

B.

objective / cause

C.

both objective and subjective / degree

D.

both objective and subjective / cause

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Question # 32

The following statement(s) can correctly be made about performance measurement systems:

1. The most difficult purpose for a performance measurement system to address is to measure changes in outcomes caused by modifications in administrative or clinical treatment processes

2. A health plan needs different performance measurement systems to evaluate its administrative services and the clinical performance of its providers

A.

Both 1 and 2

B.

1 only

C.

2 only

D.

Neither 1 nor 2

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Question # 33

One true statement about state regulation of case management activities is that the majority of states

A.

have enacted laws that list specific quality management requirements for a case management program

B.

consider case management files to be medical records that must be retained for a specified length of time

C.

view case management similarly and follow similar patterns with their laws and regulations

D.

have enacted laws or regulations requiring licensure or certification of case managers

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Question # 34

The following statement(s) can correctly be made about the use of screening for secondary prevention:

1. Screening activities may involve specialty care providers as well as primary care providers (PCPs) and the health plan

2. Secondary prevention often results in more utilization of services immediately following screening

3. Screening focuses on members who have not experienced any symptoms of a particular illness

A.

All of the above

B.

1 and 3 only

C.

2 and 3 only

D.

1 only

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Question # 35

The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

Medical management programs often require the analysis of many types of data and information. __________________ is an automated process that analyzes variables to help detect patterns and relationships in the data.

A.

Unbundling

B.

Outsourcing

C.

Data mining

D.

Drilling down

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Question # 36

The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through

1. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

2. The National Committee for Quality Assurance (NCQA)

3. The American Accreditation HealthCare Commission/URAC (URAC)

A.

All of the above

B.

1 and 2 only

C.

2 and 3 only

D.

1 only

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Question # 37

Private employers are key purchasers of health plan services. The following statement(s) can correctly be made about employer expectations about the quality and cost-effectiveness of healthcare services:

1. For both health maintenance organizations (HMOs) and non-HMO plans, employers typically have access to accreditation results and performance measurement reports to help them evaluate the quality of healthcare and service

2. Because of employers’ concern about the quality and costs of healthcare services available through health plans, direct contracting has become a dominant model among employers who sponsor health benefit programs for their employees

A.

Both 1 and 2

B.

1 only

C.

2 only

D.

Neither 1 nor 2

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Question # 38

Health plans that offer healthcare programs for Medicare beneficiaries have a strong financial incentive for identifying high-risk seniors as early as possible. The identification of high-risk seniors is typically accomplished through the use of

A.

case management

B.

geriatric evaluation and management (GEM)

C.

intervention identification

D.

interdisciplinary home care (IHC)

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Question # 39

This agency’s accreditation decisions are based on the results of an on-site survey of clinical and administrative systems and processes, as well as the health plan’s performance on selected effectiveness of care and member satisfaction measures.

A.

American Accreditation HealthCare Commission/URAC (URAC)

B.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

C.

Community Health Accreditation Program (CHAP)

D.

National Committee for Quality Assurance (NCQA)

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Question # 40

Among this agency’s accreditation programs are accreditation for preferred provider organizations (PPOs), health plan call centers, and case management organizations. This agency classifies its standards as either “shall” standards or “should” standards.

A.

American Accreditation HealthCare Commission/URAC (URAC)

B.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

C.

Community Health Accreditation Program (CHAP)

D.

National Committee for Quality Assurance (NCQA)

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Question # 41

The Carlyle Health Plan uses the following clinical outcome measures to evaluate its diabetes and asthma disease management programs:

Measure 1: The percentage of diabetic patients who receive foot exams from their providers according to the program’s recommended guidelines Measure 2: The number of asthma patients who visited emergency departments for acute asthma attacks

From the answer choices below, select the response that correctly identifies whether these measures are true outcome measures or intermediate outcome measures. Measure 1- Measure 2-

A.

Measure 1-true outcome measure Measure 2-true outcome measure

B.

Measure 1-true outcome measure Measure 2-intermediate outcome measure

C.

Measure 1-intermediate outcome measure Measure 2-true outcome measure

D.

Measure 1-intermediate outcome measure Measure 2-intermediate outcome measure

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Question # 42

Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray’s condition, her physician has prescribed Upzil, a medication that has Food and Drug Administration (FDA) approval only for the treatment of depression. Upzil has not been tested for safety or effectiveness in the treatment of migraine headache. Although Harbrace’s medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray.

In this situation, the prescribing of Upzil for Ms. Ray’s headaches is an example of

A.

a cosmetic service

B.

an investigational service

C.

an off-label use

D.

a quality-of-life service

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Question # 43

In order for a health plan’s performance-based quality improvement programs to be effective, the desired outcomes must be

A.

achievable within a specified timeframe

B.

defined in terms of multiple results

C.

expressed in subjective, qualitative terms

D.

all of the above

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Question # 44

The delivery of quality, cost-effective healthcare is a primary goal of both group healthcare and workers’ compensation programs. One difference between group healthcare and workers’ compensation is that workers’ compensation

A.

provides health and disability benefits to employees injured on the job only if the employer is at fault for the injury

B.

provides coverage for a variety of direct and indirect healthcare, disability, and workplace costs

C.

manages costs by including employee cost-sharing features in its benefit design

D.

places limits on benefits by restricting the amount of benefit payments or the number of covered hospital days or provider office visits

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Question # 45

Health plans that choose to contract with external organizations for pharmacy services typically contract with pharmacy benefit managers (PBMs). Functions that a PBM typically performs for a health plan include

1. Managing the costs of prescription drugs

2. Promoting efficient and safe drug use

3. Determining the health plan’s internal management responsibilities for pharmacy services

A.

All of the above

B.

1 and 2 only

C.

2 and 3 only

D.

1 only

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Question # 46

The Glenway Health Plan’s pharmacy and therapeutics (P&T) committee conducted pharmacoeconomic research to measure both the clinical outcomes and costs of two new cholesterol-reducing drugs. Results were presented as a ratio showing the cost required to produce a 1 mcg/l decrease in cholesterol levels. The type of pharmacoeconomic research that Glenway conducted in this situation was most likely

A.

cost-effectiveness analysis (CEA)

B.

cost-minimization analysis (CMA)

C.

cost-utility analysis (CUA)

D.

cost of illness analysis (COI)

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Question # 47

The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

The Balanced Budget Act (BBA) of 1997 established the use of ___________ to determine coverage of emergency services for Medicare and Medicaid enrollees in health plans.

A.

utilization management standards

B.

the prudent layperson standard

C.

preauthorization

D.

diagnosis-based retrospective review

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Question # 48

Some health plans administer a questionnaire known as the Behavioral Risk Factor Surveillance System (BRFSS) as part of their health risk assessment (HRA) processes. The following statements are about the BRFSS. If statements (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct statement.

A.

This questionnaire was designed specifically for use by health plans.

B.

Each health plan must use the same form of the questionnaire, with no additions or modifications.

C.

This questionnaire monitors the prevalence of the major behavioral risks associated with illness and injury among adults.

D.

All of the above statements are correct.

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