Question No. 1

The following statements are about workers' compensation provider networks. Select the answer choice containing the correct statement:

AIn order to supply a provider network to furnish healthcare to workers' compensation beneficiaries, a health plan typically uses the network that has already been created for the group health plan.

BTypically, case managers for workers' compensation programs are physical therapists.

CMost states prohibit the use of fee schedules in order to curb the rising workers' compensation healthcare costs.

DNetworks serving workers' compensation patients typically include higher concentrations of specialists than do other provider networks.

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Correct Answer: D

Question No. 2

When evaluating the success of providers in meeting standards, a health plan must make adjustments for case mix or severity. One true statement about case mix/severity adjustments is that they:

ATypically are more important in measuring the performance of PCPs than they are in measuring the performance of specialists

BHelp compensate for any unusual factors that may exist in a provider's patient population or in a particular patient

CTend to increase the number of providers who are considered to be outliers

DAllow for a more equitable comparison of data between providers of outpatient care but not providers of inpatient care

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Correct Answer: B

Question No. 3

The following statements are about factors that health plans should consider as they develop provider networks in rural and urban markets. Three of the statements are true, and one of the statements is false. Select the answer choice that contains the FALSE statement.

ACompared to providers in urban areas, providers in rural areas are less likely to offer discounts to health plans in exchange for directed patient volume.

BIn urban areas, limiting the number of specialists on a panel usually affects the network's market appeal more than does limiting the number of primary care physicians.

CThe greatest opportunity to create competition in rural areas is among the specialty providers in other nearby communities.

DTypically, hospital contracting is easier in urban areas than in rural areas.

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Correct Answer: B

Question No. 4

The following statements are about the delegation of network management activities from a health plan to another party. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:

AThe NCQA requires a health plan to conduct all delegation oversight functions rather than delegating the responsibility for oversight to another entity.

BCredentialing and UM activities are the most frequently delegated functions, whereas delegation is less common for quality management (QM) and preventive health services.

COne reason that a health plan may choose to delegate a function is because the health plan's staff seeks external expertise for the delegated activity.

DWhen the health plan delegates authority for a function, it transfers the power to conduct the function on a day-to-day basis, as well as the ultimate accountability for the function.

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Correct Answer: D

Question No. 5

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.

One statement that can correctly be made about Gardenia's two-level POS product is that

Amembers who self-refer without first seeing their PCPs will receive no benefits

Bboth Gardenia and the PCPs stand to benefit if the non-provider panels are kept relatively narrow

Cmembers will pay higher coinsurance or copayments if they first see their PCPs each time

Dthe plan offers no financial incentives to members to choose an in-network specialist over a non-network specialist

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Correct Answer: D

Free AHIP AHM-530 Exam Actual Questions

The questions for AHM-530 were last updated On Nov 18, 2024