AHM-530 Free Practice Test

- (Topic 2)
The following statements are about workers' compensation provider networks. Select the answer choice containing the correct statement:

1. A. In order to supply a provider network to furnish healthcare to workers' compensation beneficiaries, a health plan typically uses the network that has already been created for the group health plan.
2. B. Typically, case managers for workers' compensation programs are physical therapists.
3. C. Most states prohibit the use of fee schedules in order to curb the rising workers' compensation healthcare costs.
4. D. Networks serving workers' compensation patients typically include higher concentrations of specialists than do other provider networks.

Correct Answer: D

- (Topic 1)
During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider’s application. One true statement regarding this process is that the health plan

1. A. has a legal right to access a prospective provider’s confidential medical records at any time
2. B. must limit any evaluations of a prospective provider’s office to an assessment of quantitative factors, such as the number of double-booked appointments a physicianaccepts at the end of each day
3. C. is prohibited by law from conducting primary verification of such data as a prospective provider’s scope of medical malpractice insurance coverage and federal tax identification number
4. D. must complete the credentialing process before a provider signs the network contract or must include in the signed document a provision that the final contract is contingent upon the completion of the credentialing process

Correct Answer: D

- (Topic 1)
Provider panels can be either narrow or broad. Compared to a similarly sized health plan that uses a broad provider panel, a health plan that uses a narrow provider panel most likely can expect to

1. A. Experience higher contracting costs
2. B. Encounter increased difficulty in utilization management
3. C. Have to charge higher health plan premiums
4. D. Experience lower provider relations costs

Correct Answer: D

- (Topic 2)
Dr. Leona Koenig removed the appendix of a plan member of the Helium health plan. In order to increase the level of reimbursement that she would receive from Helium, Dr. Koenig submitted to the health plan separate charges for the preoperative physical examination, the surgicalprocedure, and postoperative care. All of these charges should have been included in the code for the surgical procedure itself. Dr. Koenig's submission is a misuse of the coding system used by health plans and is an example of:

1. A. Upcoding
2. B. A wrap-around
3. C. Churning
4. D. Unbundling

Correct Answer: D

- (Topic 1)
The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.
If Gladspell’s per diem contract with Ellysium is typical, then the per diem payment will cover such medical costs as

1. A. Laboratory tests
2. B. Respiratory therapy
3. C. Semiprivate room and board
4. D. Radiology services

Correct Answer: C