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AHM-540 Exam Dumps - Medical Management

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Question # 4

Most health plans require a PCP referral or precertification for CAM benefits.

A.

True

B.

False

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Question # 5

Patricia McLeod is a member of the Enterprise Health Plan, which operates in State X. Ms. McLeod is scheduled to undergo a unilateral mastectomy for the treatment of breast cancer. The surgical procedure will be performed by Dr. Kim Lee, a surgical oncologist. Based on Enterprise’s medical policy, the contract with the purchaser, and Ms. McLeod’s medical condition, Enterprise’s UR staff have determined that the appropriate course of care for Ms.

McLeod includes a 24-hour stay in the hospital following her surgery. State X, however, has a benefit mandate specifying health plan coverage for 48 hours of inpatient post-mastectomy care. In this situation, the length of hospital stay for which Enterprise must offer coverage is

A.

the length of stay deemed appropriate by Dr. Lee

B.

the 24-hour stay determined to be appropriate by Enterprise’s UR staff

C.

the length of stay deemed appropriate by Ms. McLeod

D.

the 48-hour length of stay specified by State X

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Question # 6

The case management program director at the Nova Health Plan calculated the program’s ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:

Administrative costs for case management ..........$40,000

Actual medical care expenses for patients under case management ..........$680,000

Projected medical care expenses for the same patients without case management ..........$900,000

This information indicates that, for the previous quarter, Nova’s ratio of medical expense savings to case management administrative costs was

A.

0.71/1

B.

0.80/1

C.

5.50/1

D.

1.25/1

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Question # 7

In recent years, the demand for prescription drugs has increased dramatically. Factors that have contributed to this increase include

A.

increased education regarding the purpose and benefits of drug formularies

B.

reductions in the cost of prescription drugs

C.

increased use of direct-to-consumer (DTC) advertising

D.

all of the above

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Question # 8

The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

Definitions of quality healthcare vary; however, four dimensions are essential to quality healthcare services. ________________ is the quality dimension indicating that services result in the best care for a given cost or the lowest cost for a given level of care.

A.

Accessibility

B.

Effectiveness

C.

Acceptability

D.

Efficiency

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