AHM-540 Medical Management

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Question 1

The Noble Health Plan conducted a cost/benefit analysis of the following four prescription
drugs:
BenefitCost
Drug A$525$350
Drug B$450$250
Drug C$400$200
Drug D$350$100
According to this analysis, the drug that represents the most efficient use of resources is

  • A. Drug A
  • B. Drug B
  • C. Drug C
  • D. Drug D


Answer : D

Question 2

The Fairview Health Plan uses a dual database approach to integrate information needed
for its disease management program. This information indicates that Fairview uses an
information management system that

  • A. combines all existing information from all data sources into a single comprehensive system
  • B. connects multiple databases with a central interface engine that acts as an information clearinghouse
  • C. provides an outside vendor with pertinent data that the vendor compiles into an integrated database
  • D. creates a separate database that pulls pertinent information from the health plans claims database, formats the information for easy analysis, and stores it in the separate database


Answer : D

Question 3

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

  • A. can measure and report quality only at the provider level
  • B. use a single system to deliver services to all plan members
  • C. provide an organizational focus for accountability
  • D. can use the same performance measures for all products and plans


Answer : C

Question 4

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.

  • A. The primary role of telephone triage clinical staff is to diagnose the callers condition and give medical advice.
  • B. Quality management (QM) for telephone triage programs typically focuses on the clinical information provided rather than on the quality of service.
  • C. Currently, none of the major accrediting agencies offers an accreditation program specifically for telephone triage programs.
  • D. A telephone triage program may also include a self-care component.


Answer : B

Question 5

The Medicaid population can be divided into subgroups based on their relative size and the
costs of providing benefits. From the answer choices below, select the response that
correctly identifies the subgroups that represent the largest percentages of the total
Medicaid population and of total Medicaid expenditures. Largest % of Medicaid Population-
Largest % of Medicaid Expenditures-

  • A. Largest % of Medicaid Population-dual eligibles Largest % of Medicaid Expenditures- children and low-income adults
  • B. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for MedicareLargest % of Medicaid Expenditures-dual eligibles
  • C. Largest % of Medicaid Population-children and low-income adults Largest % of Medicaid Expenditures-chronically ill or disabled individuals not eligible for Medicare
  • D. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for Medicare Largest % of Medicaid Expenditures-children and low-income adults


Answer : C

Question 6

In order to provide a true measure of quality, the data collected by a quality indicator should
accurately represent the service dimension being measured. This information indicates that
the indicator should exhibit the characteristic known as

  • A. clarity
  • B. reliability
  • C. validity
  • D. feasibility


Answer : C

Question 7

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


Answer : C

Question 8

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

  • A. provide only those benefits covered by Medicare Part A and Part B
  • B. are not subject to federal or state regulation
  • C. place primary care at the center of the delivery system
  • D. are structured as indemnity plans


Answer : C

Question 9

Occasionally, employers combine workers compensation, group healthcare, and disability
programs into an integrated product known as 24-hour coverage. One true statement about
24-hour coverage is that it typically

  • A. increases administrative costs
  • B. requires plans to maintain separate databases of patient care information
  • C. exempts plans from complying with state workers’ compensation regulations
  • D. allows plans to apply disability management and return-to-work techniques to nonoccupational conditions


Answer : D

Question 10

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

  • A. cost-based benchmarking reveals why some areas of a health plan perform better or worse than comparable areas of other organizations
  • B. diagnosis-related groups (DRGs) are a source of benchmarking data that describe individual procedures and cover both inpatient and outpatient care
  • C. patient billing records provide a much more accurate account of procedure costs for benchmarking than do current procedural terminology (CPT) codes
  • D. the focus of benchmarking for health plan has shifted from identifying the lowest cost practices to identifying best practices


Answer : D

Question 11

Examples of alternative healthcare practitioners are chiropractors, naturopaths, and
acupuncturists. The only well-established credentialing standards for alternative healthcare

  • A. chiropractors
  • B. naturopaths
  • C. acupuncturists
  • D. all of the above


Answer : A

Question 12

Health plans arrange for the delivery of various levels of healthcare, including
1.Emergency care
2.Urgent care
3.Primary care delivered in a providers office
In a ranking of these levels of care according to cost, beginning with the least expensive
level of care and ending with the most expensive level of care, the correct order would be

  • A. 1—2—3
  • B. 2—3—1
  • C. 3—1—2
  • D. 3—2—1


Answer : D

Question 13

The following statement(s) can correctly be made about medical management
considerations for the Federal Employee Health Benefits Program (FEHBP):
1.FEHBP plan members who have exhausted the health plans usual appeals process for a
disputed decision can request an independent review by the Office of Personnel
Management (OPM)
2.All health plans that cover federal employees are required to develop and implement
patient safety initiatives

  • A. Both 1 and 2
  • B. 1 only
  • C. 2 only
  • D. Neither 1 nor 2


Answer : A

Question 14

Administrative action plans are used when performance problems or opportunities are
related to the way the organization itself operates. The following statement(s) can correctly
be made about administrative action plans:
1.Administrative action plans allow health plans to coordinate management activities
2.One function of administrative action plans is to integrate service across all levels of the
organization
3.Administrative action plans are designed to improve outcomes by helping plan members
assume responsibility for their own health

  • A. All of the above
  • B. 1 and 2 only
  • C. 1 and 3 only
  • D. 2 and 3 only


Answer : B

Question 15

Health plan performance measures include structure measures, process measures, and
outcome measures. The following statements are about the characteristics of these three
types ofperformance 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.


Answer : B

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