Free Healthcare Management: An Introduction Exam AHM-250 Exam Practice Test

One factor the Sandpiper Health Plan uses to assess its quality is a clinician's bedside manner, i.e., how friendly and understanding the clinician is, whether the patient feels that the clinician listens to the patient's concerns, how well the clinical

• a provider service quality issue
• an administrative service quality issue a healthcare process quality issue
• a healthcare outcomes quality issue
• a healthcare process quality issue

The following statements describe violations of antitrust legislation:Situation A - Two health plans in a single service area divided purchasers into two groups and agreed to each market their products to only one purchaser group.Situation B - A spec

• Situation A - horizontal division of markets Situation B - tying arrangement.
• Situation A - horizontal division of markets Situation B - price fixing.
• Situation A - horizontal group boycott Situation B - tying arrangement.
• Situation A - horizontal group boycott Situation B - price fixing.

The Oriole MCO uses a typical diagnosis-related groups (DRGs) payment method to reimburse the Isle Hospital for its treatment of Oriole members. Under the DRG payment method, whenever an Oriole member is hospitalized at Isle, Oriole pays Isle

• an amount based on the weighted value of each medical procedure or service that Isle provides, and the weighted value is determined by the appropriate current procedural terminology (CPT) code for the procedure or service
• a fixed rate based on average expected use of hospital resources in a given geographical area for that DRG
• a retrospective reimbursement based on the actual costs of the Oriole member's hospitalization
• a specific negotiated amount for each day the Oriole member is hospitalized

Graff Scott is a member of the ABC Health Plan. Whenever she needs non-emergency medical care, sees Dr. Michael Chan, an internist. Ms. Scott cannot self-refer to a specialist, so she saw Dr. Michael Chan when she experienced headaches. Dr. Michael Chan referred her to Dr. Bruce Lee, a neurologist, who had hospitalized at the Polo Hospital for tests. ABC has contracts with Dr.Michael Chan, Dr. Lee, and Polo to provide medical services to its members. The following statements are about Polo's organized system of healthcare. Select the answer choice containing the correct statement

• Within Polo's system, Ms. Scott received primary care from both Dr. Michael Chan and Dr. Lee
• Polo's system allows its members open access to all of Ultra's participating providers
• Polo's network of providers includes Dr. Michael Chan and Dr. Lee but not Polo Hospital
• Within Polo's system, Dr. Michael Chan serves as a coordinator of care or gatekeeper for the medical services that Ms. Scott receives

Katrina Lopez is a claims analyst for a health plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Ms. Lopez reviewed a health claim for answers to the following questions:Question A

• A, B, C, and D
• A, B, and D only
• B, C, and D only
• A and C only

During the risk assessment process for a traditional indemnity group insurance health plan, group underwriters consider such characteristics as a group’s geographic location, the size and gender mix of the group, and the level of participation in the grou

• Healthcare costs are typically higher in rural areas than in large urban areas.
• The morbidity rate for males is higher than the morbidity rate for females.
• The larger the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.
• All of the above

Which of the following is NOT a factor that is used by MCOs to determine which services will undergo utilization review?

• Cost per procedure
• Concurrent review
• Cost of review
• Access requirements

Federal legislation has placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level.This federal legislation is the

• Clayton Act
• Federal Trade Commission Act
• McCarran-Ferguson Act
• Sherman Act

Janet Riva is covered by a indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan. She incurred

• $1,750
• $1,800
• $2,000
• $2,250

The Clover Group is a for-profit MCO that operates in the United States. The Valentine Group owns all of Clover's stock. The Valentine Group's sole business is the ownership of controlling interests in the shares of other companies. This information indic

• holding company of the Valentine Group
• sister corporation of the Valentine Group
• parent company of the Valentine Group
• subsidiary of the Valentine Group