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AHIP AHM-250 - Healthcare Management: An Introduction

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Page: 11 / 11
Total 367 questions

The following statements describe corporate transactions:

Transaction A – An MCO acquired another MCO.

Transaction B – A group of providers formed an organization to carry out billings, collections, and contracting with MCOs for the entire group of provide

A.

A and C only

B.

A, B, and C

C.

B and C only

D.

A and B only

The Links Company, which offers its employees a self-funded health plan, signed a contract with a third party administrator (TPA) to administer the plan. The TPA handles the group's membership services and claims administration. The contract between Links

A.

a manual rating contract

B.

a funding vehicle contract

C.

an administrative services only (ASO) contract

D.

a pooling contract

The following statements are about information management in health plans. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:

A.

Health plans find EDI useful for transmitting data among different health plan locations.

B.

EDI is different from eCommerce in the EDI is the transfer of data, typically in batches, while ecommerce is a back-and-forth exchange of information concerning individual transactions.

C.

The majority of health plan eCommerce occurs via proprietary computer networks.

D.

Benefits that health plans can receive from using electronic data interchange.

The following statements are about preferred provider organizations (PPOs). Select the answer choice that contains the correct statement.

A.

PPOs generally assume full financial risk for arranging medical services for their members.

B.

PPOs generally pay a larger portion of a member's medical expenses when that member uses in-network providers than when the member uses out-of-network providers.

C.

PPO networks may include primary care physicians and hospitals, but generally do not include specialists.

D.

In a PPO, the most common method used to reimburse physicians is capitation.

The Robust Health Plan sometimes uses prospective experience rating to calculate the premiums for a group. Under prospective experience rating, Robust most likely will:

A.

At the end of a rating period, the financial gains and losses experienced by the group during that rating period and, if the group's experience during the period is better than expected, refund part of the group's premium in the form of an experience ratio

B.

Use Robust's average experience with all groups to calculate this particular group's premium.

C.

Use the group's past experience to estimate the group's expected experience for the next period.

D.

All of the above

In order to measure the expenses of institutional utilization, Holt Health care group uses standard formula to calculate hospital bed stays per 1000 plan members. On 26 November, Holt uses the following information to:

Calculate the bed days per 1000 members for the MTD

Total gross hospital bed days in MTD = 500

Plan membership = 15000

Calculate Holt's number of bed days per 1000 members for the month to date, rounded to the nearest whole number.

A.

468

B.

365

C.

920

D.

500

The following statements are about concepts related to the underwriting function within a health plan. Select the answer choice containing the correct statement.

A.

Anti selection refers to the fact that individuals who believe that they have a less-than-average likelihood of loss tend to seek healthcare coverage to a greater extent than do individuals who believe that they have an average or greater-than-average like

B.

Federally qualified HMOs are required to medically underwrite all groups applying for coverage.

C.

Typically, a health plan guarantees the premium rate for a group health contract for a period of five years.

D.

When evaluating the risk for a group policy, underwriters typically focus on such factors as the size of the group, the stability of the group, and the activities of the group.

The HMO Act of 1973 was significant in that the Act

A.

mandated certain requirements that all HMOs had to meet in order to conduct business

B.

required that all HMOs be licensed as insurance companies

C.

offered HMOs federal financial assistance through grants and loans, and provided access to the employer-based insurance market

D.

encouraged the use of pre-existing condition exclusion provisions in all HMO contracts

Which of the following statements about EPO & HMO models is FALSE?

A.

In-network visit is allowed only on PCP's referral in HMO model.

B.

Out-of-network visit is not allowed in HMO model.

C.

Out-of-network visit is not allowed in EPO model.

D.

In-network visit is allowed only on PCP's referral in EPO model.

Common characteristics of POS products are

A.

Lack of Freedom of choice

B.

Absence of Primary care physician

C.

Cost-cutting efforts and the structure of coverage

D.

All of the above