AHIP AHM-250 - Healthcare Management: An Introduction

A technique used to educate plan members on how to distinguish between minor problems and serious conditions and effectively treat minor problems themselves

A technique used to determine if a health condition is present even if a member has not experienced symptoms of the problem

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

A technique used to evaluate the medical necessity, appropriateness, and cost-effectiveness of healthcare services for a given patient

users can access the Internet using a number of different types of computer systems

access to the Internet is available only to members of the health plan's network

the Internet is immune to internal security breaches by employees or trading partners within the network

users can contact a single controlling organization to rectify disruptions in Internet service

Rating Method book rating Premium Rate PMPM $132

Rating Method book rating Premium Rate PMPM $138

Rating Method blended rating Premium Rate PMPM $132

Rating Method blended rating Premium Rate PMPM $138

organizations and individuals involved in the consumption of healthcare provided by the plan

relative accessibility of the plan's providers to the plan's participants

group of physicians, hospitals, and other medical care providers with whom the plan has contracted to deliver medical services to its members

integration of the plan's participants with the plan's providers

Provide significant benefit to the community

Employ, rather than contract with, participating physicians

Achieve economies of scale through facility consolidation and practice management

Refrain from the corporate practice of medicine

1.2 million

2.2 million

3.2 million

4.2 million

COBRA

HIPAA

Medicare Modernization Act

None of the Above

should assume that all services requiring preauthorization have been preauthorized

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

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

need not determine whether the member is covered by another health plan that allows for coordination of benefits

All members of Holcomb HMO must select Dr. Phram as their primary care physician (PCP).

Any physician who meets Holcomb's standards of care is eligible to contract with Holcomb HMO as a provider.

Dr. Phram is either an employee of Holcomb HMO or belongs to a group of physicians that has contracted with Holcomb HMO

Holcomb HMO plan members may self-refer to Dr. Phram at full benefits without first obtaining a referral from their PCPs.

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

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

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

receive compensation based on a fee schedule, whereas the specialists receive compensation based on per diem charges