AHM-520 Free Practice Test

- (Topic 1)
The Cardinal health plan complies with all of the provisions of HIPAA.
Cardinal has received requests for healthcare coverage from the following companies that meet the statutory definition of a small group:
✑ The Xavier Company has excellent claims experience
✑ The Youngblood Company has not previously offered group healthcare coverage to its employees
✑ The Zebulon Company has poor claims experience
According to HIPAA's provisions, Cardinal must issue a healthcare contract to

1. A. Xavier, Youngblood, and Zebulon
2. B. Xavier and Youngblood only
3. C. Xavier only
4. D. None of these companies

Correct Answer: A

- (Topic 1)
The following statements are about various reimbursement arrangements that health plans have with hospitals. Select the answer choice containing the correct statement.

1. A. A sliding scale per-diem charges arrangement differs from a sliding scale discount on charges arrangement in that only a sliding scale per-diem charges arrangement is based on total volume of admissions and outpatient procedures.
2. B. Under a typical reimbursement arrangement that is based on diagnosisrelated groups (DRGs), if the payment amount is fixed on the basis of diagnosis, then any reduction in costs resulting from a reduction in days will go to the health plan rather than to the hospital.
3. C. A negotiated straight per-diem charge requires payment of a single charge for a day in the hospital, regardless of any actual charges or costs incurred during the hospital stay.
4. D. A straight discount on charges arrangement is the most common reimbursement method in markets with high levels of health plans.

Correct Answer: C

- (Topic 1)
The following statements illustrate common forms of capitation:
* 1. The Antler Health Plan pays the Epsilon Group, an integrated delivery system (IDS), a capitated amount to provide substantially all of the inpatient and outpatient services that Antler offers. Under this arrangement, Epsilon accepts much of the risk that utilization rates will behigher than expected. Antler retains responsibility for the plan's marketing, enrollment, premium billing, actuarial, underwriting, and member services functions.
* 2. The Bengal Health Plan pays an independent physician association (IPA) a capitated amount to provide both primary and specialty care to Bengal's plan members. The payments cover all physician services and associated diagnostic tests and laboratory work.
The physicians in the IPA determine as a group how the individual physicians will be paid for their services.
From the following answer choices, select the response that best indicates the form of capitation used by Antler and Bengal.

1. A. Antler = subcapitation Bengal = full-risk capitation
2. B. Antler = subcapitationBengal = full professional capitation
3. C. Antler = global capitation Bengal = subcapitation
4. D. Antler = global capitationBengal = full professional capitation

Correct Answer: D

- (Topic 2)
The goals of Diane Tsai, the manager of the Oval Health Plan's accounting department, and the goals of Oval are mutually supportive. Oval's accounting department is able to establish and achieve the appropriate objectives, but the department's costs of operation are too high. The following statement(s) can correctly be made about this situation:

1. A. M
2. B. Tsai most likely is the manager of a profit center.
3. C. The business goals of Oval are congruent with M
4. D. Tsai's goals.
5. E. Oval's accounting department is efficient but not effective.
6. F. All of these statements are correct.

Correct Answer: B

- (Topic 1)
The following statement(s) can correctly be made about a health plan's underwriting of small groups:

1. A. Typically, a health plan medically underwrites both the employees of a small group and their dependents, even though small group reform laws prohibit health plans from singling out individuals for rejection or substandard rate-ups.
2. B. In the absence of laws mandating otherwise, a health plan's underwriting standardsgrow stricter as group size gets smaller.
3. C. Both A and B
4. D. A only
5. E. B only
6. F. Neither A nor B

Correct Answer: A