AHM-540 Questions and Answers

Emilio Martinez, a member of the Bloom Health Plan, has recently been diagnosed with prostate cancer by his physician, Dr. Robert Cohen. Mr. Martinez has decided to participate in Bloom’s shared decision-making program for prostate cancer. On the basis of this information, it is most likely correct to say

1. That verification of Mr. Martinez’s understanding about his care options protects both Dr. Cohen and Bloom against charges of malpractice

2. That Mr. Martinez and Dr. Cohen will discuss the care options available to Mr. Martinez, but the ultimate decision about care is up to Dr. Cohen

All states have laws describing the conditions under which pharmacists can substitute a generic drug for a brand-name drug. With respect to these laws, it is correct to say that in every state,

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

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

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

This agency’s accreditation decisions are based on the results of an on-site survey of clinical and administrative systems and processes, as well as the health plan’s performance on selected effectiveness of care and member satisfaction measures.

Three general categories of coverage policy—medical policy, benefits administration policy, and administrative policy—are used in conjunction with purchaser contracts to determine a health plan’s coverage of healthcare services and supplies. With respect to the characteristics of the three types of coverage policy, it is correct to say that a health plan’s

The Brighton Health Plan regularly performs prospective UR for surgical procedures. Brighton’s prospective UR activities are likely to include

Comorbidity can have a significant impact on the effective implementation of disease management programs. Comorbidity can correctly be defined as the

A health plan’s 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 plan’s 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

For this question, if answer choices (a) through (c) are all correct, select answer choice (d). Otherwise, select the one correct answer choice.

Well-crafted clinical practice guidelines (CPGs) can benefit healthcare delivery processes and outcomes by

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

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.

Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans typically use home healthcare include

1. The period prior to a hospital admission

2. The period following discharge from a hospital

The following statements are about the use of provider profiling for pharmacy benefits. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

Increased demands for performance information have resulted in the development of various health plan report cards. With respect to most of the report cards currently available, it is correct to say

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

Each quality standard used by a health plan is associated with quality indicators. A ______________ indicator is a form of aggregate data indicator that produces results that fit within a specified range, such as the length of time to schedule an appointment.

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

To facilitate electronic commerce (eCommerce), a health plan may establish a secured extranet. One true statement about a secured extranet is that it is