AHM-540 Certification Guide

1. http://www.certschief.comCertification Preparation Material AHIP AHM-540 AHM Medical Management Exam Demo Product - For More Information - Visit: http://www.certschief.com/exam/AHM-540/ Edition = DEMO ProductFull Version Features:  90 Days Free Updates  30 Days Money Back Guarantee  Instant Download Once Purchased  24/7 Online Chat Support Page | 1 http://www.certschief.com/exam/AHM-540/

2. http://www.certschief.comCertification Preparation Material Question: 1 By definition, the development and implementation of parameters for the delivery of healthcare services to a health plan’s members is known as A. utilization management (UM) B. quality management (QM) C. care management D. clinical practice management Answer: D Question: 2 Determine whether the following statement is true or false: With respect to the size of a managed care organization (MCO) and its medical management operations, it is correct to say that large health plans typically have more integration among activities and less specialization of roles than do small MCOs. A. True B. False Answer: B Question: 3 With respect to the activities of MCO medical directors, it is correct to say that medical directors typically perform all of the following activities EXCEPT A. maintaining clinical practices B. delivering performance feedback to providers C. participating in utilization management (UM) activities D. educating other MCO staff about new clinical developments or provider innovations that might impact clinical practice management Answer: A Question: 4 The paragraph below contains two pairs of terms enclosed in parentheses. Select the term in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen. Under a delegation arrangement, the (delegate / delegator) is responsible for performing the delegated function according to established standards, and the (delegate / delegator) is ultimately accountable for any deficiencies in the performance of the function. A. delegate / delegate B. delegate / delegator C. delegator / delegate D. delegator / delegator Answer: B Page | 2 http://www.certschief.com/exam/AHM-540/

3. http://www.certschief.comCertification Preparation Material Question: 5 Determine whether the following statement is true or false: The delegation of medical management functions to providers can occur without the transfer of financial risk. A. True B. False Answer: A Question: 6 For this question, if answer choices (1) through (3) are all correct, select answer choice (4). Otherwise, select the one correct answer choice. Health plans sometimes delegate selected medical management activities to their providers or other external entities. Activities that are frequently delegated include A. utilization review (UR) B. quality management (QM) C. preventive health services D. all of the above Answer: A Question: 7 MCOs usually have a formal program for the oversight of delegated activities. The following statements concern typical delegation oversight programs. Select the answer choice containing the correct statement. A. A letter of intent is the contractual document that describes the delegated functions and the responsibilities of the MCO and the delegate. B. In most cases, the evaluation of a candidate for delegation is based entirely on the candidate’s application and supporting documentation and does not include an on-site assessment of the candidate. C. Under most delegation agreements, an MCO cannot terminate the agreement before the end date stated in the agreement. D. One objective for a delegation oversight program is to integrate any delegated activities into the MCO’s overall programs for medical management and other functions. Answer: D Question: 8 The Riverside Health Plan is considering the following provider compensation options to use in its contracts with several provider groups and hospitals: A discounted fee-for-service (DFFS) payment system A case rate system Capitation If Riverside wants to use only those compensation methods that encourage the efficient use of resources, then the compensation method(s) that Riverside should consider for its new contracts include A. 1, 2, and 3 Page | 3 http://www.certschief.com/exam/AHM-540/

4. http://www.certschief.comCertification Preparation Material B. 1 and 2 only C. 2 and 3 only D. 3 only Answer: C Question: 9 To facilitate electronic commerce (eCommerce), a health plan may establish a secured extranet. One true statement about a secured extranet is that it is A. based on Web-based technologies B. available only to the employees of the health plan C. publicly available, so the potential exists for unauthorized access to a health plan’s proprietary systems D. used to handle the majority of health plan eCommerce Answer: A Question: 10 The following statements are about health plans’ use of electronic data interchange (EDI). Three of the statements are true and one is false. Select the answer choice containing the FALSE ALSE statement. A. One advantage of EDI over manual data management systems is improved data integrity. B. EDI may use the Internet as the communication link between the participating parties. C. EDI involves back-and-forth exchanges of information concerning individual transactions. D. The data format for EDI is agreed upon by the sending and receiving parties. Answer: C Question: 11 For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say A. that the construction of a data warehouse is quick and simple B. that a data warehouse addresses the problems associated with multiple data management systems C. that a data warehouse stores only current data D. all of the above Answer: B Question: 12 The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph. Medical management programs often require the analysis of many types of data and information. __________________ is an automated process that analyzes variables to help detect patterns and relationships in the data. A. Unbundling Page | 4 http://www.certschief.com/exam/AHM-540/

5. http://www.certschief.comCertification Preparation Material B. Outsourcing C. Data mining D. Drilling down Answer: C Question: 13 One method of transferring the information in electronic medical records (EMRs) is through a health information network (HIN). The following statements are about HINs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement. A. A HIN may afford a health plan better measurements of outcomes and provider performance. B. The use of a HIN typically increases a health plan’s exposure to liability for poor care. C. Most HINs are Internet-based rather than built on proprietary computer networks. D. Currently, the majority of health plans do not have HINs that are capable of transferring medical records among their network providers. Answer: B Question: 14 Private employers are key purchasers of health plan services. The following statement(s) can correctly be made about employer expectations about the quality and cost-effectiveness of healthcare services: For both health maintenance organizations (HMOs) and non-HMO plans, employers typically have access to accreditation results and performance measurement reports to help them evaluate the quality of healthcare and service Because of employers’ concern about the quality and costs of healthcare services available through health plans, direct contracting has become a dominant model among employers who sponsor health benefit programs for their employees A. Both 1 and 2 B. 1 only C. 2 only D. Neither 1 nor 2 Answer: D Question: 15 State governments serve as both regulators and purchasers of health plan services. The influence of state governments as purchasers is focused on A. Medicare and TRICARE programs B. Medicaid and workers’ compensation programs C. Medicare and Medicaid programs D. TRICARE and workers’ compensation programs Answer: B Question: 16 Page | 5 http://www.certschief.com/exam/AHM-540/

6. http://www.certschief.comCertification Preparation Material Federal laws, such as the Employee Retirement Income Security Act (ERISA), the Balanced Budget Act (BBA) of 1997, and the Health Insurance Portability and Accountability Act (HIPAA), have affected medical management activities by health plans. Consider the following provisions of federal regulations: Provision 1—Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered treatment and does not allow health plan members to obtain compensatory or punitive damages Provision 2—Establishes electronic data security standards, which define the security measures that healthcare organizations must take to protect the confidentiality of electronically stored and transmitted patient information From the answer choices below, select the response that correctly identifies the federal laws that include Provision 1 and Provision 2, respectively. A. Provision 1- ERISA Provision 2- HIPAA B. Provision 1- HIPAA Provision 2- ERISA C. Provision 1- BBA of 1997 Provision 2- HIPAA D. Provision 1- ERISA Provision 2- BBA of 1997 Answer: A Question: 17 The Quality Assessment Performance Improvement (QAPI) is a quality initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare and Medicaid health plan enrollees. The Centers for Medicare and Medicaid Services (CMS) requires compliance with QAPI from A. both Medicare+Choice plans and Medicaid health plans B. Medicare+Choice plans only C. Medicaid health plans only D. neither Medicare+Choice plans nor Medicaid health plans Answer: B Page | 6 http://www.certschief.com/exam/AHM-540/

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