AHM-540 Practice Exam Questions with Answers Medical Management Certification

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.

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

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

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.

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

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.

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

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

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.

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

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.

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,

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.

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.

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.

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.

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

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.

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

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

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

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

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

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

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

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.

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

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

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

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.

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)

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

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

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.

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.

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-

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

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

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

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

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

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.

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.