AHIP Healthcare Management: An Introduction Questions + Answers

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Question 1 ( Topic 1 )
By definition, the marketing process of defining a certain place or market niche for a product relative to competitors and their products and then using the marketing mix to attract certain market segments is known as
A. branding
B. positioning
C. database marketing
D. personal selling


Answer : B

Question 2 ( Topic 1 )
By definition, a health plan's network refers to the
A. organizations and individuals involved in the consumption of healthcare provided by the plan
B. relative accessibility of the plan's providers to the plan's participants
C. group of physicians, hospitals, and other medical care providers with whom the plan has contracted to deliver medical services to its members
D. integration of the plan's participants with the plan's providers


Answer : C

Question 3 ( Topic 1 )
Col. Martin Avery, on active duty in the U.S. Army, iseligibleto receive healthcare benefits under one of the three TRICARE health plan options. If Col Avery elects to participate in

TRICARE Prime, he will be -
A. able to obtain full benefits for services obtained from network and non-network providers
B. subject to copayment, deductible, and coinsurance requirements for any medical care he receives
C. required to formally enroll for coverage and pay an enrollment fee
D. assigned to a primary care manager who is responsible for coordinating all his care


Answer : D

Question 4 ( Topic 1 )
Greentree Medical, a health plan, is currently recruiting PCPs in preparation for its expansion into a new service area. Abigail Davis, a recruiter for Greentree, has been meeting with Melissa Cortelyou, M.D., in an effort to recruit her as a PCP in Green
A. Greentree is prevented by law from offering a contract to Dr. Cortelyou until the credentialing process is complete
B. any contract signed by Dr. Cortelyou should include a clause requiring the successful completion of the credentialing process within a defined time frame in order for the contract to be effective
C. Greentree must offer a standard contract to Dr. Cortelyou, without regard to the outcome of the credentialing process
D. Greentree will abandon the credentialing process now that Dr. Cortelyou has agreed to participate in Greentree's network


Answer : B

Question 5 ( Topic 1 )
If a state commissioner of insurance places an HMO under administrative supervision, then the purpose of this action most likely is to:
A. Transfer all of the HMO's business to other carriers.
B. Allow the state commissioner, acting for a state court, to take control of and administer the HMO's assets and liabilities.
C. Sell the HMO's assets in order to satisfy the HMO's obligations.
D. Place the HMO's operations under the direction and control of the state commissioner or a person appointed by the commissioner.


Answer : D



Question 10 ( Topic 1 )
Health plans' use of the Internet to provide plan members with health-related information has grown rapidly in recent years. One advantage the Internet has over other forms of communication is that
A. users can access the Internet using a number of different types of computer systems
B. access to the Internet is available only to members of the health plan's network
C. the Internet is immune to internal security breaches by employees or trading partners within the network
D. users can contact a single controlling organization to rectify disruptions in Internet service


Answer : A


Question 11 ( Topic 1 )
In claims administration terminology, a claims investigation is correctly defined as the process of
A. reporting management information about services provided each time a patient visits a provider for purposes of analyzing utilization and provider practice patterns
B. obtaining all the information necessary to determine the appropriate amount to pay on a given claim
C. routinely reviewing and processing a claim for either payment or denial
D. assigning to each diagnosis or treatment reported on a claim special codes that briefly and specifically describe each diagnosis and treatment


Answer : B

Question 12 ( Topic 1 )
Al Marak, a member of the Frazier Health Plan, has asked for a typical Level One appeal of a decision that Frazier made regarding Mr. Marak's coverage. One true statement about this Level One appeal is that
A. Mr. Marak has the right to appeal to the next level if the Level One appeal upholds the original decision
B. It requires Frazier and Mr. Marak to submit to arbitration in order to resolve the dispute
C. It is considered to be an informal appeal
D. It will be handled by an independent review organization (IRO)


Answer : A

Question 13 ( Topic 1 )
A public employer, such as a municipality or county government would be considered which of the following?
A. Employer-employee group
B. Multiple-employer group
C. Affinity group
D. Debtor-creditor group


Answer : A

Question 14 ( Topic 1 )
In order to cover some of the gap between FFS Medicare coverage and the actual cost of services, beneficiaries often rely on Medicare supplements. Which of the following statements about Medicare supplements is correct?
A. The initial ten (A-J) Medigap policies offer a basic benefit package that includes coverage for Medicare Part A and Medicare Part B coinsurance.
B. Each insurance company selling Medigap must sell all the different Medigap policies.
C. Medicare SELECT is a Medicare supplement that uses a preferred provider organization (PPO) to supplement Medicare Part A coverage.
D. Medigap benefits vary by plan type (A through L), and are not uniform nationally.


Answer : A

Question 15 ( Topic 1 )
If most of the physicians, or many of the physicians in a particular specialty, are affiliated with a single entity, then a health plan building a network in the service area
_____________.
A. Has many contracting options available.
B. Should not contract with that entity
C. Most likely needs to contract with that entity
D. Should attempt to disband the existing affiliations



Question 16 ( Topic 1 )
In 1999, the United States Congress passed the Financial Services Modernization Act, which is referred to as the Gramm-Leach-Bliley (GLB) Act. The following statement(s) can correctly be made about this act:
A. The GLB Act allows convergence among the transaction
B. A only
C. Both A and B
D. B only
E. Neither A nor B


Answer : B

Question 17 ( Topic 1 )
Before an HMO contracts with a physician, the HMO first verifies the physician's credentials.
Upon becoming part of the HMO's organized system of healthcare, the physician is typically subject to
A. both recredentialing and peer review
B. recredentialing only
C. peer review only
D. neither recredentialing nor peer review


Answer : C

Question 18 ( Topic 1 )
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
A. Prospective review
B. Concurrent review
C.
D. A, B, and C
E. A and B only
F. A and C only
G. B only


Answer : B

Question 19 ( Topic 1 )
For providers, integration occurs when two or more previously separate providers combine under common ownership or control, or when two or more providers combine business operations that they previously carried out separately and independently. Such provi
A. higher costs for health plans, healthcare purchasers, and healthcare consumers
B. improved provider contracting position with health plans
C. an increase in providers' autonomy and control over their own work environment
D. all of the above


Answer : B

Question 20 ( Topic 1 )
Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.
A. The Serenity Healthcare Organization requires a plan member or the provider in charge of the member's care to obtain authorization for inpatient care before the member is admitted to the hospital.
B. UR nurses employed by the Friendship Health Plan monitor length of stay to identify factors that might contribute to unnecessary hospital days.
C. The Optimum Health Group evaluates the medical necessity and appropriateness of proposed services and intervenes, if necessary, to redirect care to a more appropriate care setting.
D. The Axis Medical Group examines provider practice patterns to identify areas in which services are being underused, overused, or misused and designs strategies to prevent inappropriate utilization in the future.


Answer : D



Question 21 ( Topic 1 )
From the answer choices below, select the response that correctly identifies the rating method that Mr. Sybex used and the premium rate PMPM that Mr. Sybex calculated for the
Koster group.
A. Rating Method book rating Premium Rate PMPM $132
B. Rating Method book rating Premium Rate PMPM $138
C. Rating Method blended rating Premium Rate PMPM $132
D. Rating Method blended rating Premium Rate PMPM $138


Answer : C

Question 22 ( Topic 1 )
Health savings accounts were created by which of the following laws:
A. COBRA
B. HIPAA
C. Medicare Modernization Act
D. None of the Above


Answer : C

Question 23 ( Topic 1 )
Bart Vereen is insured by both a traditional indemnity health insurance plan, which is his primary plan, and a managed care plan. Both plans have a typical coordination of benefits
(COB) provision, but neither plan has a nonduplication of benefits provision
A. 380
B. 130
C. 0
D. 550


Answer : A

Question 24 ( Topic 1 )
From the following choices, choose the definition that best matches the term health risk assessment (HRA)
A. A technique used to educate plan members on how to distinguish between minor problems and serious conditions and effectively treat minor problems themselves
B. A technique used to determine if a health condition is present even if a member has not experienced symptoms of the problem
C. A technique in which information about a plan member's health status, personal and family health history, and health-related behaviors is used to predict the member's likelihood of experiencing specific illnesses or injuries
D. A technique used to evaluate the medical necessity, appropriateness, and cost- effectiveness of healthcare services for a given patient


Answer : C

Question 25 ( Topic 1 )
______________ HMOs can't medically underwrite any group – incl small groups.
A. State
B. Not-for-profit
C. For-profit
D. Federally qualified


Answer : B


Question 26 ( Topic 1 )
Health plans require utilization review for all services administered by its participating physicians.
A. True
B. False


Answer : B

Question 27 ( Topic 1 )
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy
A. Health plans and their providers are obligated not to harm their members
B. Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a group
C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members
D. Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives


Answer : D

Question 28 ( Topic 1 )
In the following sections, we will describe some of the measures health plans use to evaluate the quality of the services and healthcare they offer their members.
Which of the following is the best description of what a 'Process measure' evaluates?
A. The nature, quantity, and quality of the resources that a health plan has available for member service and patient care.
B. The methods and procedures a health plan and its providers use to furnish service and care.
C. The extent to which services succeed in improving or maintaining satisfaction and patient health.
D. None of the above


Answer : B

Question 29 ( Topic 1 )
From the following choices, choose the definition that best matches the term Screening
A. A technique used to educate plan members on how to distinguish between minor problems and serious conditions and effectively treat minor problems themselves
B. A technique used to determine if a health condition is present even if a member has not experienced symptoms of the problem
C. A technique in which information about a plan member's health status, personal and family health history, and health-related behaviors is used to predict the member's likelihood of experiencing specific illnesses or injuries
D. A technique used to evaluate the medical necessity, appropriateness, and cost- effectiveness of healthcare services for a given patient


Answer : B

Question 30 ( Topic 1 )
Beginning in the early 1980s, several factors contributed to increased demand for behavioral healthcare services. These factors included
A. increased stress on individuals and families
B. increased availability of behavioral healthcare services
C. greater awareness and acceptance of behavioral healthcare issues
D. all of the above


Answer : D


Question 31 ( Topic 1 )
Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in-network than for services received out-of-network.
Whenever Mr. Murray receives a health claim from a plan member, he reviews the claim
A. A, B, C, and D
B. A and C only
C. A, B, and D only
D. B, C, and D only


Answer : A

Question 32 ( Topic 1 )
Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called:
A. Codes
B. Lists
C. Edits
D. Checks


Answer : C

Question 33 ( Topic 1 )
In the paragraph below, a sentence contains two pairs of words enclosed in parentheses.
Determine which word in each pair correctly completes the sentence. Then select the answer choice containing the two words that you have chosen. Many pharmacy benefit
A. Therapeutic / always
B. Generic / always
C. Generic / never
D. Therapeutic / never


Answer : A

Question 34 ( Topic 1 )
Health plans can organize under a not-for-profit form or a for-profit form. One true statement regarding not-for-profit health plans is that these organizations typically
A. are exempt from review by the Internal Revenue Service (IRS)
B. are organized as stock companies for greater flexibility in raising capital
C. rely on income from operations for the large cash outlays needed to fund long-term projects and expansion
D. engage in lobbying or political activities in order to maintain their tax-exempt status


Answer : C

Question 35 ( Topic 1 )
Brokers are one type of distribution channel that health plans use to market their health plans. One true statement about brokers for health plan products is that, typically, brokers
A. Are not required to be licensed by the states in which they market health plans
B. Are compensated on a salary basis
C. Represent only one health plan or insurer
D. Are considered to be an agent of the buyer rather than an agent of the health plan or Insurer


Answer : D


Question 36 ( Topic 1 )
Consumer-directed health plans are not a new concept. They actually got their start in the late 1970s with the advent of:
A. Health savings accounts (HSAs)
B. Health reimbursement arrangements (HRAs)
C. Medical savings accounts (MSAs)
D. Flexible spending arrangements (FSAs)


Answer : D

Question 37 ( Topic 1 )
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence
A. Health plans and their providers are obligated not to harm their members
B. Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a group
C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members
D. Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives


Answer : B

Question 38 ( Topic 1 )
Ian Vladmir wants to have a routine physical examination to ascertain that he is in good health. Mr. Vladmir is a member of a health plan that will allow him to select the physician of his choice, either from within his plan's network or from outside of h
A. a traditional HMO plan
B. a managed indemnity plan
C. a point of service (POS) option
D. an exclusive provider organization (EPO)


Answer : C

Question 39 ( Topic 1 )
All CDHP products provide federal tax advantages while allowing consumers to save money for their healthcare.
A. True
B. False


Answer : A

Question 40 ( Topic 1 )
The following statements describe two types, or models, of HMOs:
The Quest HMO has contracted with only one multi-specialty group of physicians. These physicians are employees of the group practice, have an equity interest in the practice, and provide
A. A captive group a staff model
B. A captive group a network model
C. An independent group a network model
D. An independent group a staff model


Answer : B


Question 41 ( Topic 1 )
Ashley Martin is covered by a managed healthcare plan that specifies a $300 deductible and includes a 30% coinsurance provision for all healthcare obtained outside the plans network of providers. In 1998, Ms. Martin became ill while she was on vacation,
A. $300
B. $510
C. $600
D. $810


Answer : D

Question 42 ( Topic 1 )
Before the Hill Health Maintenance Organization (HMO) received a certificate of authority
(COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the
A. Hill had to have an initial net worth of at least $1.5 million in order to obtain a COA.
B. The COA most likely exempts Hill from any of State X's enabling statutes.
C. Hill had to be organized as a partnership in order to obtain a COA
D. The COA in no way indicates that Hill has demonstrated that it is fiscally sound.


Answer : A

Question 43 ( Topic 1 )
In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known
A. dual choice
B. cost shifting
C. accreditation
D. defensive medicine


Answer : B

Question 44 ( Topic 1 )
Because many patients with behavioral health disorders do not require round-the-clock nursing care and supervision, behavioral healthcare services can be delivered effectively in a variety of settings. For example, post-acute care for behavioral health di
A. Hospital observation units or psychiatric hospitals.
B. Psychiatric hospitals or rehabilitation hospitals.
C. Subacute care facilities or skilled nursing facilities.
D. Psychiatric units in general hospitals or hospital observation units.


Answer : C

Question 45 ( Topic 1 )
By offering a comprehensive set of healthcare benefits to its members, an HMO ensures that its members obtain quality, cost-effective, and appropriate medical care. Ways that an
HMO provides comprehensive care include
A. coordinating care across a variety of benefits
B. emphasizing preventive care by covering many preventive services either in full or with a small copayment
C. offering its members access to wellness programs
D. All of the above


Answer : D


Question 46 ( Topic 1 )
Dr. Julia Phram is a cardiologist under contract to Holcomb HMO, Inc., a typical closed- panel plan. The following statements are about this situation. Select the answer choice containing the correct statement.
A. All members of Holcomb HMO must select Dr. Phram as their primary care physician (PCP).
B. Any physician who meets Holcomb's standards of care is eligible to contract with Holcomb HMO as a provider.
C. Dr. Phram is either an employee of Holcomb HMO or belongs to a group of physicians that has contracted with Holcomb HMO
D. Holcomb HMO plan members may self-refer to Dr. Phram at full benefits without first obtaining a referral from their PCPs.


Answer : A

Question 47 ( Topic 1 )
Federal legislation has placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level.

This federal legislation is the -
A. Clayton Act
B. Federal Trade Commission Act
C. McCarran-Ferguson Act
D. Sherman Act


Answer : C

Question 48 ( Topic 1 )
Before the Leo Health Maintenance Organization (HMO) received a certificate of authority
(COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the
A. receive compensation based on the volume and variety for medical services they perform for Leo plan members, whereas the specialists receive compensation based solely on the number of plan members who are covered for specific services
B. have no financial incentive to practice preventive care or to focus on improving the health of their plan members, whereas the specialists have a positive incentive to help their plan members stay healthy
C. receive from the IPA the same monthly compensation for each Leo plan member under the PCP's care, whereas the specialists receive compensation based on a percentage discount from their normal fees
D. receive compensation based on a fee schedule, whereas the specialists receive compensation based on per diem charges


Answer : C

Question 49 ( Topic 1 )
Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further investigation of a claim. In an automated claims processing system, these criteria may signal the need for further review when, for example
A. Encounter reports
B. Diagnostic codes
C. Durational ratings
D. Edits


Answer : D

Question 50 ( Topic 1 )
Bill Clinton is a member of Lewinsky's PBM plan which has a three-tier copayment structure. Bill fell ill and his doctor prescribed him AAA, a brand-name drug which was included in the Lewinsky's formulary; BBB, a non-formulary drug; and CCC, a generic dr
A. CCC, AAA, BBB
B. BBB, CCC, AAA
C. BBB, AAA, CCC
D. CCC, BBB, AAA


Answer : A


Question 51 ( Topic 1 )
Arthur Moyer is covered under his employer's group health plan, which must comply with the Consolidated Omnibus Budget Reconciliation Act (COBRA). Mr. Moyer is terminating his employment. He has elected to continue his coverage under his employer's group
A. 18 months, but his coverage under COBRA will cease if he obtains group health coverage through another employer.
B. 18 months, even if he obtains group health coverage through another employer.
C. 36 months, but his coverage under COBRA will cease if he obtains group health coverage through another employer.
D. 36 months, even if he obtains group health coverage through another employer.


Answer : A

Question 52 ( Topic 1 )
During the risk assessment process for a traditional indemnity group insurance health plan, group underwriters consider such characteristics as a groups geographic location, the size and gender mix of the group, and the level of participation in the grou
A. Healthcare costs are typically higher in rural areas than in large urban areas.
B. The morbidity rate for males is higher than the morbidity rate for females.
C. The larger the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.
D. All of the above


Answer : C

Question 53 ( Topic 1 )
After a somewhat modest start in 2004, enrollment in HSA-related health plans more than tripled in 2005, making them todays fastest growing type of CDHP. As of January 2006, enrollment in HSAs had reached nearly:
A. 1.2 million
B. 2.2 million
C. 3.2 million
D. 4.2 million


Answer : B

Question 54 ( Topic 1 )
A health savings account must be coupled with an HDHP that meets federal requirements for minimum deductible and maximum out-of-pocket expenses. Dollar amounts are indexed annually for inflation. For 2006, the annual deductible for self-only coverage must
A. $525
B. $1,050
C. $2,100
D. $5,250


Answer : B

Question 55 ( Topic 1 )
A physician-hospital organization (PHO) may be classified as an open PHO or a closed
PHO. With respect to a closed PHO, it is correct to say that
A. the specialists in the PHO are typically compensated on a capitation basis
B. the specialists in the PHO are typically compensated on a capitation basis
C. it typically limits the number of specialists by type of specialty
D. it is available to a hospital's entire eligible medical staff
E. physician membership in the PHO is limited to PCPs


Answer : B


Question 56 ( Topic 1 )
In accounting terminology, the items of value that a company owns—such as cash, cash equivalents, and receivables—are generally known as the company's
A. revenue
B. net income
C. surplus
D. assets


Answer : D

Question 57 ( Topic 1 )
Before the Hill Health Maintenance Organization (HMO) received a certificate of authority
(COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the
A. Receive compensation based on the volume and variety of medical services they perform for Hill plan members, whereas the specialists receive compensation based solely on the number of plan members who are covered for specific services.
B. Have no financial incentive to practice preventive care or to focus on improving the health of their plan members, whereas the specialists have a positive incentive to help their plan members stay healthy.
C. Receive from the IPA the same monthly compensation for each Hill plan member under the PCP's care, whereas the specialists receive compensation based on a percentage discount from their normal fees.
D. Receive compensation based on a fee schedule, whereas the specialists receive compensation based on per diem charges.


Answer : C

Question 58 ( Topic 1 )
Immediate evaluation and treatment of illness or injury can be provided in any of the following care settings:
A. Hospital emergency departments
B. Physician's offices
C. Urgent care centers If these settings are ranked in order of the cost of providing c
D. A, B, C
E. A, C, B
F. B, C, A
G. C, A, B


Answer : B

Question 59 ( Topic 1 )
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy
A. Health plans and their providers are obligated not to harm their members
B. Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a group
C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members
D. Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives


Answer : D

Question 60 ( Topic 1 )
Although the process is voluntary for health plans, external accreditation is becoming more and more important as states and purchasers require health plans undergo as many states and purchasers require health plans undergo some type of external review pr
A. Is voluntary for health plans.
B. Requires all change accreditation organizations to use the same standards of accreditation.
C. Typically requires the accrediting organization to conduct a medical record review and a review of a health plan's credentialing processes, but not an evaluation of the health plans' member service systems processes.
D. Cannot assure that a health plan meets a specified level of quality.


Answer : A


Question 61 ( Topic 1 )
If left unresolved, member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info
A. A Level One appeal, and the member has the right to a further appeal
B. A Level Two appeal, and the reviewer's decision is final and binding
C. An independent external appeal, and the member has the right to a further appeal
D. Arbitration, and the reviewer's decision is final and binding


Answer : A

Question 62 ( Topic 1 )
Historically most HMOs have been
A. Closed-access HMO
B. Closed-panel HMO
C. Open-access HMO
D. Open-panel HMO


Answer : B

Question 63 ( Topic 1 )
Eleanor Giambi is covered by a typical 24-hour managed care program. One characteristic of this program is that it:
A. Provides Ms. Giambi with healthcare coverage for any illness or injury, but only if the cause of the illness or injury is work-related.
B. Combines the group health plan and disability plan offered by Ms. Giambi's employer with workers' compensation coverage.
C. Requires Ms. Giambi and her employer to each pay half of the cost of this coverage.
D. Requires Ms. Giambi to pay specified deductibles and copayments before receiving benefits under this program for any illness or injury.


Answer : B

Question 64 ( Topic 1 )
In order to measure the expenses of institutional utilization, Holt Healthcare Group uses the standard formula to calculate hospital bed days per 1,000 plan members per year. On
October 23, Holt used the following information to calculate the bed days per
A. 278
B. 397
C. 403
D. 920


Answer : B

Question 65 ( Topic 1 )
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
A. Prospective review
B. Concurrent review
C.
D. A, B, and C
E. A and B only
F. A and C only
G. B only


Answer : D


Question 66 ( Topic 1 )
As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members:
-> Brad Van Note, age 28, is taking many different, costly medications for
A. Mr. Van Note, Mr. Albrecht, and Ms. Cromartie
B. Mr. Van Note and Ms. Cromartie only
C. Mr. Van Note and Mr. Albrecht only
D. Mr. Albrecht and Ms. Cromartie only


Answer : C

Question 67 ( Topic 1 )
An exclusive provider organization (EPO) operates much like a PPO. However, one difference between an EPO and a PPO is that an EPO
A. Is regulated under federal HMO legislation
B. Generally provides no benefits for out-of-network care
C. Has no provider network of physicians
D. Is not subject to state insurance laws


Answer : B

Question 68 ( Topic 1 )
Dr. Milton Ware, a physician in the Riverside MCO's network of providers, is reimbursed under a fee schedule arrangement for medical services he provides to Riverside members.
Dr. Ware's provider contract with Riverside contains a typical no-balance billi
A. prevent Dr. Ware from requiring a Riverside member to pay any coinsurance, copayment, or deductibles that the member would normally pay under Riverside's plan
B. require Dr. Ware to accept the amount that Riverside pays for medical services as payment in full and not to bill plan members for additional amounts
C. prevent Dr. Ware from seeking compensation from patients if Riverside fails to compensate him because of the MCO's insolvency
D. prevent Dr. Ware from billing a Riverside member for medical services that are not included in Riverside's plan


Answer : B

Question 69 ( Topic 1 )
During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, fo
A. the angina, the high blood pressure, and the broken ankle
B. the angina and the high blood pressure only
C. none of these conditions
D. the broken ankle only


Answer : A

Question 70 ( Topic 1 )
A medical foundation is a not-for-profit entity that purchases and manages physician practices. In order to retain its not-for-profit status, a medical foundation must
A. Provide significant benefit to the community
B. Employ, rather than contract with, participating physicians
C. Achieve economies of scale through facility consolidation and practice management
D. Refrain from the corporate practice of medicine


Answer : A



Question 71 ( Topic 1 )
Amendments to the HMO act 1973 do not permit federally qualified HMO’s to use
A. Retrospective experience rating
B. Adjusted community rating
C. Community rating by class
D. Community rating


Answer : A

Question 72 ( Topic 1 )
Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. The primary purpose of this clause is to:
A. State that Dr. Aldridge's provider contract with Badger will automatically terminate if he loses his medical license or hospital privileges.
B. Specify a time period during which the party that breaches the provider contract must remedy the problem in order to avoid termination of the contract.
C. Give Dr. Aldridge the right to appeal Badger's decision if he is terminated with cause from Badger's provider network.
D. Specify that Badger can terminate this provider contract without providing a reason, but only if Badger gives Dr. Aldridge at least 90-days' notice of its intent to terminate the contract.


Answer : C

Question 73 ( Topic 1 )
Emily Brown works for Integral Health Plan and represents the company as a board member for the board of directors. Which best describes Emily's position?
A. Community Representative
B. Inside Director
C. Outside Director
D. None of these


Answer : B

Question 74 ( Topic 1 )
In assessing the potential degree of risk represented by a proposed insured, a health underwriter considers the factor of anti selection. Anti selection can correctly be defined as the
A. inability of a proposed insured to share with the insurer the financial risks of healthcare coverage
B. possibility that a proposed insured will profit from an illness by receiving benefits that exceed the total amount of his or her eligible medical expenses
C. inability of a proposed insured to provide sufficient evidence that proves he or she is an insurable risk
D. tendency of people who have a greater-than-average likelihood of loss to apply for or continue insurance protection to a greater extent than people who have an average or less than average likelihood of the same loss


Answer : D

Question 75 ( Topic 1 )
A particular health plan offers a higher level of benefits for services provided in-network than for out-of-network services. This health plan requires preauthorization for certain medical services.
With regard to the steps that the health plan's claims e
A. should assume that all services requiring preauthorization have been preauthorized
B. should investigate any conflicts between diagnostic codes and treatment codes before approving the claim to ensure that the appropriate payment is made for the claim
C. need not verify that the provider is part of the health plan's network before approving the claim at the in-network level of benefits
D. need not determine whether the member is covered by another health plan that allows for coordination of benefits


Answer : B


Question 76 ( Topic 1 )
Identify the CORRECT statement(s):
(A) Smaller the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.
(B) Gender of the group's participants has no effect on the likelihood of loss.
A. All of the listed options
B. B & C
C. None of the listed options
D. A & C


Answer : C

Question 77 ( Topic 1 )
In health plan terminology, demand management, as used by health plans, can best be described as
A. an evaluation of the medical necessity, efficiency, and/or appropriateness of healthcare services and treatment plans for a given patient
B. a series of strategies designed to reduce plan members' needs to utilize healthcare services by encouraging preventive care, wellness, member self-care, and appropriate use of healthcare services
C. a technique that prevents a provider who is being reimbursed under a fee schedule arrangement from billing a plan member for any fees that exceed the maximum fee reimbursed by the plan
D. a system of identifying plan members with special healthcare needs, developing a healthcare strategy to meet those needs, and coordinating and monitoring the care


Answer : B

Question 78 ( Topic 1 )
General HMO is building a provider network and is considering Universal Hospital as an addition to its network. Minimum requirements that General should consider in determining whether Universal is qualified to participate in General's network include A.
A. Both A and B
B. A only
C. B only
D. Neither A nor B


Answer : A

Question 79 ( Topic 1 )
A health plan's ability to establish an effective provider network depends on the characteristics of the proposed service area and the needs of proposed plan members. It is generally correct to say that
A. health plans have more contracting options if providers are affiliated with single entities than if providers are affiliated with multiple entities
B. urban areas offer more flexibility in provider contracting than do rural areas
C. consumers and purchasers in markets with little health plan activity are likely to be more receptive to HMOs than to loosely managed plans such as PPOs
D. large employers tend to adopt health plans more slowly than do small companies


Answer : B

Question 80 ( Topic 1 )
Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. Specialty services that have certain characteristics are generally good candidates for health pl
A. Low or stable costs.
B. Appropriate, rather than inappropriate, utilization rates.
C. A benefit that cannot be easily defined.
D. Defined patient population.


Answer : D


Question 81 ( Topic 1 )
In response to the demand for a method of assessing outcomes, accrediting organizations and other government and commercial groups have developed quantitative measures of quality that consumers, purchasers, regulators, and others can use to compare health
A. quality standards
B. accreditation decisions
C. standards of care
D. performance measures


Answer : D

Question 82 ( Topic 1 )
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence
A. Health plans and their providers are obligated not to harm their members
B. Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a group
C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members
D. Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives


Answer : B

Question 83 ( Topic 1 )
Employer-sponsored benefit plans that provide healthcare benefits must comply with the
Employee Retirement Income Security Act (ERISA). One of the most significant features of

ERISA is that it -
A. contains a provision stating that the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plans
B. standardizes the conversion of group healthcare benefits to individual healthcare benefits
C. mandates that self-funded healthcare plans must pay state premium taxes
D. requires that all active employees, regardless of age, must be eligible for coverage under employer-sponsored benefit plans


Answer : A

Question 84 ( Topic 1 )
According to the IRS, which of the following is not an allowable preventive care service?
A. Smoking cessation programs.
B. Periodic health examinations.
C. Health club memberships.
D. Immunizations for children and adults.


Answer : C

Question 85 ( Topic 1 )
As part of its quality management program, the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. When Lyric concludes that its competitor's practices or services are better than its own, Lyric im
A. Benchmarking.
B. Standard of care.
C. An adverse event.
D. Case-mix adjustment.


Answer : A