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  • Exam Name: Medical Management
  • Last Update: 29-May-2024
  • Questions and Answers: 163
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AHM-540 Questions and Answers

Question # 1

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.

Question # 2

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.

Question # 3

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

Question # 4

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

Question # 5

Michelle Durden, who is enrolled in a dental health maintenance organizations (DHMO) offered by her employer, is due for a routine dental examination. If the plan is typical of most DHMOs, then Ms. Durden

A.

must pay the entire cost of the examination

B.

must obtain a referral to a dentist from her primary care provider (PCP)

C.

can schedule the examination without preauthorization of payment by the DHMO

D.

can schedule an unlimited number of examinations and cleanings per year

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