AHM-540 Exam Dumps - Medical Management
Most health plans require a PCP referral or precertification for CAM benefits.
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
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
In recent years, the demand for prescription drugs has increased dramatically. Factors that have contributed to this increase include
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.
By definition, the development and implementation of parameters for the delivery of healthcare services to a health plan’s members is known as
Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray’s condition, her physician has prescribed Upzil, a medication that has Food and Drug Administration (FDA) approval only for the treatment of depression. Upzil has not been tested for safety or effectiveness in the treatment of migraine headache. Although Harbrace’s medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray.
The following statement(s) can correctly be made about Harbrace’s use of extra-contractual coverage:
1. Harbrace’s medical policy most likely establishes the procedure that Harbrace used to evaluate the value of Upzil for treating Ms. Ray
2. One way for Harbrace to reduce the risk associated with extra-contractual coverage is by including an alternative care provision in its contracts with purchasers
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
The Garnet Health Plan uses provider profiling to measure and improve provider performance. Provider profiling most likely allows Garnet to
The following statements are about chronic and disabling conditions among children eligible for Medicaid. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
Health plans arrange for the delivery of various levels of healthcare, including
1. Emergency care
2. Urgent care
3. Primary care delivered in a provider’s 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
Some health plans administer a questionnaire known as the Behavioral Risk Factor Surveillance System (BRFSS) as part of their health risk assessment (HRA) processes. The following statements are about the BRFSS. If statements (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct statement.
Examples of alternative healthcare practitioners are chiropractors, naturopaths, and acupuncturists. The only well-established credentialing standards for alternative healthcare practitioners are those available from NCQA. These NCQA credentialing standards apply to
Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.
Due to competitive pressures and consumer demand, many health plans now offer direct access or open access products. Under a direct access product, a member is (required / not required) to select a primary care provider (PCP), and is (required / not required) to obtain a referral from a PCP or the health plan before visiting a network specialist.
Readiness is an important consideration for the development of health promotion programs. Readiness refers to
Determine whether the following statement is true or false:
Under a carve-out arrangement for disease management, patients typically maintain their existing relationships with primary care providers (PCPs) for all care, including disease management.
The delivery of quality, cost-effective healthcare is a primary goal of both group healthcare and workers’ compensation programs. One difference between group healthcare and workers’ compensation is that workers’ compensation
Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.
The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Greenhouse’s prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).
Accreditation is intended to help purchasers and consumers make decisions about healthcare coverage.
The following statements are about accreditation. Select the answer choice containing the correct statement.