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  • Exam Name: Network Management
  • Last Update: 16-Apr-2024
  • Questions and Answers: 202
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AHM-530 Questions and Answers

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:

A.

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

B.

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

C.

Receives 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.

D.

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

Question # 2

Partial capitation is one common approach to capitation. One typical characteristic of partial capitation is that it:

A.

Includes only primary care services

B.

Covers such services as immunizations and laboratory tests

C.

Can be used only if the provider's panel size is less than 50 providers

D.

Covers such services as cardiology and orthopedics

Question # 3

One difference between a fee-for-service (FFS) reimbursement arrangement and capitation is that the FFS arrangement:

A.

Is a prospective payment system, whereas capitation is a retrospective payment system

B.

Has a potential to induce providers to underutilize medical resources, whereas capitation does not have this potential disadvantage

C.

Bases the amount of reimbursement on the actual medical services delivered, whereas reimbursement under capitation is independent of the actual volume and cost of services provided

D.

Is most often used by health plans to reimburse healthcare facilities, whereas capitation is most often used by health plans to reimburse specialty care providers

Question # 4

Dr. Ahmad Shah and Dr. Shantelle Owen provide primary care services to Medicare+Choice enrollees of health plans under the following physician incentive plans:

Dr. Shah receives $40 per enrollee per month for providing primary care and an additional $10 per enrollee per month if the cost of referral services falls below a specified level

Dr. Owen receives $30 per enrollee per month for providing primary care and an additional $15 per enrollee per month if the cost of referral services falls below a specified level

The use of a physician incentive plan creates substantial risk for

A.

Both Dr. Shah and Dr. Owen

B.

Dr. Shah only

C.

Dr. Owen only

D.

Neither Dr. Shah nor Dr. Owen

Question # 5

Following statements are about accreditation of health plans:

A.

The National Committee for Quality Assurance (NCQA) serves as the primary accrediting agency for most health maintenance organizations (HMOs).

B.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has developed standards that can be used for the accreditation of hospitals, but not for the accreditation of health plan provider networks or health plan plans.

C.

States are required to adopt the model standards developed by the National Association of Insurance Commissioners (NAIC), an organization of state insurance regulators that develops standards to promote uniformity in insurance regulations.

D.

Accreditation is an evaluative process in which a health plan undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the federal government or by the state governments.

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