AHM-510

AHM-510 practice questions, page 2 of 3, with answer review and explanations.

Question 6

The Hanford Health Plan has delegated the credentialing of its providers to the Sienna Group, a credential verification organization (CVO). If the contract between Hanford and Sienna complies with all of the National Committee for Quality Assurance (NCQA) guidelines for delegation of credentialing, then this contract:

  1. Transfers to Sienna all rights to terminate or suspend individual practitioners or providers in Hanford's provider network
  2. Describes the process by which Hanford evaluates Sienna's performance in credentialing providers
  3. Both A and B
  4. A only
  5. B only
  6. Neither A nor B

Question 7

Congress enacted three clauses relating to the preemptive effect of the Employee Retirement Income Security Act of 1974 (ERISA). One of these clauses preserves from ERISA preemption any state law that regulates insurance, banking, or securities, with the exception of the exemption for self-funded employee benefit plans. This clause is called the:

  1. Savings clause
  2. Preemption clause
  3. Deemer clause
  4. De novo clause

Question 8

Any willing provider laws have their share of proponents and opponents. Arguments commonly made in opposition to any willing provider laws include:

  1. That such laws reduce the number of providers in a health plan's network
  2. That such laws limit consumer choice to coverage options that are more costly than network based plans
  3. That such laws encourage providers to offer discounts in exchange for patient volume
  4. All of the above

Question 9

The Sawgrass Health Center is an institution that trains healthcare professionals and performs various clinical and other types of healthcare-related research. Because Sawgrass receives government funding, it is required to provide medical care for the poor. Of the following types of health plans, Sawgrass can best be described as:

  1. A medical foundation
  2. An academic medical center (AMC)
  3. A healthcare cooperative
  4. A community health center (CHC)

Question 10

Arthur Dace, a plan member of the Bloom health plan, tried repeatedly over an extended period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr. Dace informally surveyed other Bloom plan members and found that many people were experiencing similar problems getting an appointment with this particular provider. Mr. Dace threatened to take legal action against Bloom, alleging that the health plan had deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making it difficult for patients to make appointments with Dr. Pyle. Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR) method that is quicker and less expensive than litigation. Under this ADR method, both Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who issued a decision that Bloom's utilization management practices in this case did not constitute a form of abuse. The panel's decision is legally binding on both parties. Different types of compensation arrangements in managed care plans, from fee-for-service (FFS) arrangements to capitation arrangements, lead to different types of fraud and abuse. From the answer choices below, select the response that identifies the form of abuse in which Bloom is allegedly engaging, according to Mr. Dace's complaint, and whether this form of abuse is more likely to occur in FFS compensation arrangements or in capitation arrangements.

  1. Type of abuse underutilization - Type of compensation arrangement FFS arrangement
  2. Type of abuse underutilization - Type of compensation arrangement capitation arrangement
  3. Type of abuse overutilization - Type of compensation arrangement FFS arrangement
  4. Type of abuse overutilization - Type of compensation arrangement capitation arrangement