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Exam : AHM-530

Title : Network Management

Vendor : AHIP

Version : DEMO

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NO.1 With regard to the compensation of dental care providers in a managed dental care system, it is
correct to state that, typically:
A. dental PPOs compensate dentists on a capitated basis
B. group model dental HMOs (DHMOs) compensate general dental practitioners on a salaried basis
C. independent practice association (IPA)-model dental HMOs (DHMOs) capitate general dental
practitioners
D. staff model dental HMOs (DHMOs) compensate dentists on an FFS basis
Answer: C

NO.2 The Portway Hospital is qualified to receive Medicaid subsidy payments as a disproportionate
share hospital (DHS). The DHS payments that Portway receives are
A. Made for services rendered to specific patients
B. Made with matching state and federal funds
C. Included in the Medicaid capitation payment made to patients' health plans
D. Defined as cost-based reimbursement (CBR) equal to 100% of Portway's reasonable costs of
providing services to Medicaid recipients
Answer: B

NO.3 The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:
A. Must provide Medicare participants with standard HMO benefits, as well as with limited long-term
care benefits
B. Does not need as great a variety of provider types or as complex a reimbursement method as does
a traditional HMO
C. Receives a payment that is based on reasonable costs and reasonable charges
D. Most likely provides fewer supportive services than does a traditional HMO, because one of Bruin's
goals is to minimize the use of community-based care
Answer: A

NO.4 Dr. Sarah Carmichael is one of several network providers who serve on one of the Apex Health
Plan's organizational committees. The committee reviews cases against providers identified through
complaints and grievances or through clinical monitoring activities. If needed, the committee
formulates, approves, and monitors corrective action plans for providers. Although Apex
administrators and other employees also serve on the committee, only participating providers have
voting rights. The committee that Dr. Carmichael serves on is a
A. Utilization management committee
B. Peer review committee
C. Medical advisory committee
D. Credentialing committee
Answer: B

NO.5 Health plans typically conduct two types of reviews of a provider's medical records: an
evaluation of the provider's medical record keeping (MRK) practices and a medical record review
(MRR). One true statement about these types of reviews is that:

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A. An MRK covers the content of specific patient records of a provider.

B. The NCQA requires an examination of MRK with all of a health plan's office evaluations.
C. An MRR includes a review of the policies, procedures, and documentation standards the provider
follows to create and maintain medical records.
D. The NCQA requires MRR for both credentialing and recredentialing of providers in a health plan's
network.
Answer: A

NO.6 In open panel contracting, there are several types of delivery systems. One such delivery system
is the faculty practice plan (FPP). One likely result that a health plan will experience by contracting
with an FPP is that the health plan will
A. be able to select most of the physicians in the FPP
B. achieve the highest level of cost effectiveness possible
C. experience limited control over utilization
D. achieve the most effective case management possible
Answer: C

NO.7 The Ionic Group, a provider group with 10,000 plan members, purchased for its hospital risk
pool aggregate stop-loss insurance with a threshold of 110% of projected costs and a 10%
coinsurance provision. Ionic funds the hospital risk pool at $40 per member per month (PMPM).
If Ionic's actual hospital costs are $5,580,000 for the year, then, under the aggregate stop-loss
agreement, the stop-loss insurer is responsible for reimbursing Ionic in the amount of
A. $30,000
B. $270,000
C. $300,000
D. $702,000
Answer: B

NO.8 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.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated
whether:
A. Dr. Enberg's young patients receive appropriate immunizations at the right ages
B. Dr. Enberg's young patients receive appropriate immunizations at the right ages
C. The condition of one of Dr. Enberg's patients improved after the patient received medical

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treatment from Dr. Enberg

D. Dr. Enberg's procedures are adequate for ensuring patients' access to medical care
Answer: A

NO.9 In the paragraph below, two statements each contain a pair of terms enclosed in parentheses.
Determine which term correctly completes each statement. Then select the answer choice that
contains the two terms you have chosen.
In most states, a health plan can be held responsible for a provider's negligent malpractice. This legal
concept is known as (vicarious liability / risk sharing). One step that health plans can take to reduce
their exposure to malpractice lawsuits is to state in health plan-provider agreements,marketing
collateral, and membership literature that the providers are (employees of the health plan /
independent contractors).
A. Vicarious liability / employees of the health plan
B. Vicarious liability / independent contractors
C. Risk sharing / employees of the health plan
D. Risk sharing / independent contractors
Answer: B

NO.10 With respect to contractual provisions related to provider-patient communications,

nonsolicitation clauses prohibit providers from
A. Encouraging patients to switch from one health plan to another
B. Disclosing confidential information about the health plan's reimbursement structure
C. Dispersing confidential financial information regarding the health plan
D. Discussing alternative treatment plans with patients
Answer: A

NO.11 The Adobe Health Plan complies with all of the provisions of the Newborns' and Mothers'
Health Protection Act (NMHPA) of 1996. Kristen Netzger, an Adobe enrollee, was hospitalized for a
cesarean delivery. Amy Davis, also an Adobe enrollee, was hospitalized for a normal delivery. From
the following answer choices, select the response that indicates the minimum length of time for
which Adobe, under NMHPA, most likely must provide benefits for the hospitalizations of Ms.
Netzger and Ms. Davis.
A. Ms. Netzger = 48 hours Ms. Davis = 48 hours
B. Ms. Netzger = 72 hours Ms. Davis = 72 hours
C. Ms. Netzger = 96 hours Ms. Davis = 48 hours
D. Ms. Netzger = 96 hours Ms. Davis = 72 hours
Answer: C

NO.12 Under the compensation arrangement that the Falcon Health Plan has with some of its
providers, Falcon holds back 10% of the negotiated payments to these providers in order to offset or
pay for any claims that exceed the budgeted costs for referral or hospital services. If the providers
keep costs within the budgeted amount, Falcon distributes to them the entire amount of money held
back. This way of motivating providers to control costs while providing high-quality, appropriate care

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is known as a:
A. Risk pool arrangement
B. Withhold arrangement
C. Cost-shifting arrangement
D. Bonus pool arrangement
Answer: B

NO.13 In 1996, the NAIC adopted a standard for health plan coverage of emergency services. This
standard is based on a concept known as the:
A. Due process standard
B. Subrogation standard
C. Corrective action standard
D. Prudent layperson standard
Answer: D

NO.14 The following statement(s) can correctly be made about contracting and reimbursement of
specialty care physicians (SCPs):
A. Typically, a health plan should attempt to control utilization of SCPs before attempting to place
these providers under a capitation arrangement.
B. Forms of specialty physician reimbursement used by health plans include a retainer and a bundled
case rate.
C. Both A and B
D. A only
E. B only
F. Neither A nor B
Answer: A

NO.15 One true statement about the compensation arrangement known as the case rate system is
that, under this system,
A. Providers stand to gain or lose based on the number and types of treatments used for each case
B. Providers have no incentives to take an active role in managing cost and utilization
C. Payors cannot adjust standard case rates to reflect the severity of the patient's condition or
complications that arise from multiple medical problems
D. Payors have the opportunity to benefit from the provider's cost savings
Answer: A

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