AHM-530

AHM-530 practice questions, page 3 of 8, with answer review and explanations.

Question 11

From the following answer choices, choose the term that best matches the description. Members of a physician-hospital organization (PHO) denied membership to a physician solely because the physician has admitting privileges at a competing hospital.

  1. Group boycott
  2. Horizontal division of territories
  3. Tying arrangements
  4. Concerted refusal to admit

Question 12

Some states have enacted any willing provider laws. From the perspective of the health plan industry, one drawback of any willing provider laws is that they often result in a reduction of a plan's:

  1. Premium rates
  2. Ability to monitor utilization
  3. Number of primary care providers (PCPs)
  4. Number of specialists and ancillary providers

Question 13

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).

  1. Vicarious liability / employees of the health plan
  2. Vicarious liability / independent contractors
  3. Risk sharing / employees of the health plan
  4. Risk sharing / independent contractors

Question 14

The National Committee for Quality Assurance (NCQA) has integrated accreditation with Health Employer Data and Information Set (HEDIS) measures into a program called Accreditation '99. One statement that can correctly be made about these accreditation standards is that:

  1. Health plans are required by law to report HEDIS results to NCQA
  2. HEDIS restricts its reporting criteria to a narrow group of quantitative performance measures, while NCQA includes a broad range of qualitative performance measures
  3. Private employer groups purchasing health care coverage increasingly require both NCQA accreditation and HEDIS reporting
  4. HEDIS includes measures of a health plan's effectiveness of care rather than its cost of care

Question 15

The National Association of Insurance Commissioners (NAIC) Managed Care Plan Network Adequacy Model Act defines specific adequacy and accessibility standards that health plans must meet. In addition, the Model Act requires health plans to:

  1. Hold plan members responsible for unreimbursed charges or unpaid claims
  2. Allow providers to develop their own standards of care
  3. Adhere to specified disclosure requirements related to provider contract termination
  4. File written access plans and sample contracts with the Centers for Medicaid and Medicare Services (CMS)