AHIP Medical Management Questions + Answers

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Question 1
PBMs are accredited by the same organizations that accredit health plans.
A. True
B. False


Answer : B

Question 2
The Westchester Health Plan classifies its key processes into the following categories: high-risk, high-volume, problem-prone, and high-cost. Westchester also prioritizes the categories in terms of importance. The process category that Westchester most likely ranks highest in importance is
A. High-risk processes
B. High-volume processes
C. Problem-prone processes
D. High-cost processes


Answer : A

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
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 1Limits 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 2Establishes 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 5
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 6
Performance variance can be classified as either common cause variance or special cause variance. The following statement(s) can correctly be made about special cause variance:
1.Inadequate staffing levels, employee errors, and equipment malfunctions are examples of special cause variance
2.Special cause variance is typically more difficult to detect and correct than is common cause variance
A. Both 1 and 2
B. 1 only
C. 2 only
D. Neither 1 nor 2


Answer : B

Question 7
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

Question 8
A health plan's preventive care initiatives may be classified into three main categories: primary prevention, secondary prevention, and tertiary prevention. Secondary prevention refers to activities designed to
A. develop an appropriate treatment strategy for patients whose conditions require extensive, complex healthcare
B. educate and motivate members to prevent illness through their lifestyle choices
C. prevent the occurrence of illness or injury
D. detect a medical condition in its early stages and prevent or at least delay disease progression and complications


Answer : D

Question 9
Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Rays 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
Harbraces 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 Harbraces use of extra- contractual coverage:
1.Harbraces 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
A. Both 1 and 2
B. 1 only
C. 2 only
D. Neither 1 nor 2


Answer : C

Question 10
Determine whether the following statement is true or false:
Independent review organizations (IROs) can mediate disputes and offer advisory opinions to health plans on UR issues, but they cannot render binding decisions on appeals.
A. True
B. False


Answer : B


Question 11
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 plans proprietary systems
D. used to handle the majority of health plan eCommerce


Answer : A

Question 12
The Brighton Health Plan regularly performs prospective UR for surgical procedures.
Brightons prospective UR activities are likely to include
A. documenting the clinical details of the patient’s condition and care
B. tracking the length of inpatient stay
C. completing the discharge planning process
D. determining the most appropriate setting for the proposed course of care


Answer : D

Question 13
Health plans that choose to contract with external organizations for pharmacy services typically contract with pharmacy benefit managers (PBMs). Functions that a PBM typically performs for a health plan include
1.Managing the costs of prescription drugs
2.Promoting efficient and safe drug use
3.Determining the health plans internal management responsibilities for pharmacy services
A. All of the above
B. 1 and 2 only
C. 2 and 3 only
D. 1 only


Answer : B

Question 14
The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self- care most likely would not be appropriate.
A. Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area.
B. Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day.
C. Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility.
D. Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.


Answer : A

Question 15
In order for a health plans performance-based quality improvement programs to be effective, the desired outcomes must be
A. achievable within a specified timeframe
B. defined in terms of multiple results
C. expressed in subjective, qualitative terms
D. all of the above


Answer : A


Question 16
The Noble Health Plan conducted a cost/benefit analysis of the following four prescription drugs:

BenefitCost -

Drug A$525$350 -

Drug B$450$250 -

Drug C$400$200 -

Drug D$350$100 -
According to this analysis, the drug that represents the most efficient use of resources is
A. Drug A
B. Drug B
C. Drug C
D. Drug D


Answer : D

Question 17
The Fairview Health Plan uses a dual database approach to integrate information needed for its disease management program. This information indicates that Fairview uses an information management system that
A. combines all existing information from all data sources into a single comprehensive system
B. connects multiple databases with a central interface engine that acts as an information clearinghouse
C. provides an outside vendor with pertinent data that the vendor compiles into an integrated database
D. creates a separate database that pulls pertinent information from the health plans claims database, formats the information for easy analysis, and stores it in the separate database


Answer : D

Question 18
Comparing the quality of managed Medicare programs with the quality of FFS Medicare programs is often difficult. Unlike FFS Medicare, managed Medicare programs
A. can measure and report quality only at the provider level
B. use a single system to deliver services to all plan members
C. provide an organizational focus for accountability
D. can use the same performance measures for all products and plans


Answer : C

Question 19
To improve members abilities to make appropriate care decisions about specific medical problems, some health plans use a form of decision support known as telephone triage programs. The following statements are about telephone triage programs. Select the answer choice containing the correct statement.
A. The primary role of telephone triage clinical staff is to diagnose the callers condition and give medical advice.
B. Quality management (QM) for telephone triage programs typically focuses on the clinical information provided rather than on the quality of service.
C. Currently, none of the major accrediting agencies offers an accreditation program specifically for telephone triage programs.
D. A telephone triage program may also include a self-care component.


Answer : B

Question 20
The Medicaid population can be divided into subgroups based on their relative size and the costs of providing benefits. From the answer choices below, select the response that correctly identifies the subgroups that represent the largest percentages of the total
Medicaid population and of total Medicaid expenditures. Largest % of Medicaid Population-
Largest % of Medicaid Expenditures-
A. Largest % of Medicaid Population-dual eligibles Largest % of Medicaid Expenditures- children and low-income adults
B. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for MedicareLargest % of Medicaid Expenditures-dual eligibles
C. Largest % of Medicaid Population-children and low-income adults Largest % of Medicaid Expenditures-chronically ill or disabled individuals not eligible for Medicare
D. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for Medicare Largest % of Medicaid Expenditures-children and low-income adults


Answer : C


Question 21
In order to provide a true measure of quality, the data collected by a quality indicator should accurately represent the service dimension being measured. This information indicates that the indicator should exhibit the characteristic known as
A. clarity
B. reliability
C. validity
D. feasibility


Answer : C

Question 22
Michelle Durden, who is enrolled in a dental health maintenance organizations (DHMO) offered by her employer, is due for a routine dental examination. If the plan is typical of most DHMOs, then Ms. Durden
A. must pay the entire cost of the examination
B. must obtain a referral to a dentist from her primary care provider (PCP)
C. can schedule the examination without preauthorization of payment by the DHMO
D. can schedule an unlimited number of examinations and cleanings per year


Answer : C

Question 23
Medicare beneficiaries can obtain healthcare benefits through fee-for-service (FFS)
Medicare programs, Medicare medical savings account (MSA) plans, Medigap insurance, or coordinated care plans (CCPs). Unlike other coverage options, CCPs
A. provide only those benefits covered by Medicare Part A and Part B
B. are not subject to federal or state regulation
C. place primary care at the center of the delivery system
D. are structured as indemnity plans


Answer : C

Question 24
Occasionally, employers combine workers compensation, group healthcare, and disability programs into an integrated product known as 24-hour coverage. One true statement about
24-hour coverage is that it typically
A. increases administrative costs
B. requires plans to maintain separate databases of patient care information
C. exempts plans from complying with state workers’ compensation regulations
D. allows plans to apply disability management and return-to-work techniques to nonoccupational conditions


Answer : D

Question 25
Benchmarking is a quality improvement strategy used by some health plans. With regard to benchmarking, it is correct to say that
A. cost-based benchmarking reveals why some areas of a health plan perform better or worse than comparable areas of other organizations
B. diagnosis-related groups (DRGs) are a source of benchmarking data that describe individual procedures and cover both inpatient and outpatient care
C. patient billing records provide a much more accurate account of procedure costs for benchmarking than do current procedural terminology (CPT) codes
D. the focus of benchmarking for health plan has shifted from identifying the lowest cost practices to identifying best practices


Answer : D


Question 26
Examples of alternative healthcare practitioners are chiropractors, naturopaths, and acupuncturists. The only well-established credentialing standards for alternative healthcare
A. chiropractors
B. naturopaths
C. acupuncturists
D. all of the above


Answer : A

Question 27
Health plans arrange for the delivery of various levels of healthcare, including
1.Emergency care
2.Urgent care
3.Primary care delivered in a providers 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
A. 1—2—3
B. 2—3—1
C. 3—1—2
D. 3—2—1


Answer : D

Question 28
The following statement(s) can correctly be made about medical management considerations for the Federal Employee Health Benefits Program (FEHBP):
1.FEHBP plan members who have exhausted the health plans usual appeals process for a disputed decision can request an independent review by the Office of Personnel
Management (OPM)
2.All health plans that cover federal employees are required to develop and implement patient safety initiatives
A. Both 1 and 2
B. 1 only
C. 2 only
D. Neither 1 nor 2


Answer : A

Question 29
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
A. All of the above
B. 1 and 2 only
C. 1 and 3 only
D. 2 and 3 only


Answer : B

Question 30
Health plan performance measures include structure measures, process measures, and outcome measures. The following statements are about the characteristics of these three types ofperformance measures. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
A. The most widely used structure measures relate to physician education and training.
B. One advantage of structure measures over process measures is that structures are often linked directly to healthcare outcomes.
C. Process measures are useful in identifying underuse, overuse, and inappropriate use of services.
D. One disadvantage of outcome measures is that they can be influenced by factors outside the control of the health plan.


Answer : B


Question 31
Most health plans require a PCP referral or precertification for CAM benefits.
A. True
B. False


Answer : B

Question 32
A health plans coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions:
1.In case of conflict between the purchaser contract and a health plans medical policy or benefits administration policy, the contract takes precedence
2.Purchaser contracts commonly exclude custodial care from their coverage of services and supplies
3.All of the criteria for coverage decisions must be included in the purchaser contract
A. All of the above
B. 1 and 2 only
C. 2 only
D. 3 only


Answer : B

Question 33
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:
1. 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
2. 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 34
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.
If Ms. Stanley agrees to the generic substitution, she will receive a drug that
A. has not been tested for safety and efficacy in large clinical trials
B. is available without a prescription at a reasonable cost
C. has been classified by the Food and Drug Administration (FDA) as safe, but that has not been proven fully effective
D. contains active ingredients that are identical to those of the prescribed brand-name drug


Answer : D

Question 35
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.
Greenhouses prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).
A. open / mandatory
B. open / voluntary
C. closed / mandatory
D. closed / voluntary


Answer : C