Medical Management (AHM-540) Free Practice Test

Question 1

This agency oversees the Federal Employee Health Benefits Program (FEHBP).

A. Office of Personnel Management (OPM)

B. Department of Justice (DOJ)

C. Health Resources and Services Administration (HRSA)

D. Department of Health and Human Services (HHS)

Correct Answer: A

Question 2

When conducting performance assessment, a health pln may classify the key processes associated with its services into the following categories: high-risk, high-volume, problem-prone, and high-cost.
The following statements are about this classification of processes. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A. Each process must be classified into a single category.

B. High-risk processes most often involve medical interventions or treatment plans for acute illnesses or case management processes for complex conditions.

C. In some instances, relatively inexpensive processes can qualify as high-cost processes.

D. Administrative processes such as scheduling appointments are examples of high-volume processes.

Correct Answer: A

Question 3

The paragraph below contains two pairs of terms in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Health plans use both internal and external standards to assess the quality of the services that they provide. (Internal / External) standards are based on information such as published industry-wide averages or best practices of recognized industry leaders. Health plans primarily rely on (internal / external) standards to evaluate healthcare services.

A. Internal / internal

B. External / internal

C. External / external

D. Internal / external

Correct Answer: C

Question 4

The Hall Health Plan gathered objective clinical information about the recommended uses and dosages of angiotensin-converting enzyme (ACE) inhibitors and presented the information to network providers to illustrate the appropriate use of these frequently prescribed and expensive drugs. This information indicates that Hall most likely educated its network providers through the use of

A. counter detailing

B. cognitive services

C. detailing

D. drug efficacy study implementation (DESI)

Correct Answer: A

Question 5

The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through
1.The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
2.The National Committee for Quality Assurance (NCQA)
3.The American Accreditation HealthCare Commission/URAC (URAC)

A. 1 only

B. 1 and 2 only

C. All of the above

D. 2 and 3 only

Correct Answer: B

Question 6

Recent laws and regulations have established new requirements for Medicaid eligibility. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 affected Medicaid eligibility by

A. severing the link between Medicaid and public assistance

B. eliminating the need for applications for Medicaid and public assistance

C. allowing states to provide healthcare benefits to groups outside the traditional Medicaid population

D. providing supplemental funding for dual eligibles in the form of five-year block grants

Correct Answer: A

Question 7

Nilay Sharma suffered a small wound while working in his yard and was taken to a local hospital for treatment. A triage nurse at the hospital evaluated Mr. Sharma's condition and directed him to an outpatient unit in the hospital where a physician assistant examined, cleaned, and sutured the wound. Mr. Sharma returned home following treatment. The care Mr. Sharma received at the hospital is an example of the type of care known as

A. specialty referral

B. urgent care

C. primary prevention

D. emergency care

Correct Answer: B

Question 8

One difference between outcomes research and clinical research is that outcomes research

A. focuses on treatment effectiveness, whereas clinical research focuses on treatment efficacy

B. gathers outcomes data from controlled clinical trials, whereas clinical research collects and analyzes clinical, financial, and administrative data

C. provides an absolute measure of treatment results, whereas clinical research provides a relative measure of results

D. examines diseases and treatments in isolation, whereas clinical research considers the effects of changes in health status and quality of life

Correct Answer: A

Question 9

Most health plans require a PCP referral or precertification for CAM benefits.

A. False

B. True

Correct Answer: A

Question 10

Health plan performance measures include structure measures, process measures, and outcome measures. The following statements are about the characteristics of these three types ofperformance measures. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

A. Process measures are useful in identifying underuse, overuse, and inappropriate use of services.

B. The most widely used structure measures relate to physician education and training.

C. One advantage of structure measures over process measures is that structures are often linked directly to healthcare outcomes.

D. One disadvantage of outcome measures is that they can be influenced by factors outside the control of the health plan.

Correct Answer: C

Question 11

A health plan's choice of structure measures, process measures, and outcome measures to evaluate performance depends in part on the scientific soundness of the measures. One approach that a health plan can use to enhance scientific soundness is stratification, which refers to the

A. statistical adjustment of outcome measures to account for differences in the severity of illness or the presence of other medical conditions

B. elimination of variation within a patient population by dividing the population into groups that are at a similar level of risk

C. identification and removal of unusual cases, such as patients with contraindications to a particular treatment, from consideration

D. specification of a target population for a procedure and the data collection and analysis methods to be used

Correct Answer: B

Question 12

Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.
The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Greenhouse's prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).

A. open / voluntary

B. open / mandatory

C. closed / voluntary

D. closed / mandatory

Correct Answer: D

Question 13

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

A. that they are used to rank the performance of various health plans

B. that they are based on data collected for the Health Plan Employer Data and Information Set (HEDIS) 3.0

C. that they are focused primarily on health maintenance organization (HMO) plans

D. all of the above

Correct Answer: D

Question 14

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
The QAPI (Quality Assessment Performance Improvement Program) is a Centers for Medicaid and Medicare Services (CMS) initiative designed to strengthen health plans' efforts to protect and improve the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standards apply to

A. services offered to Medicare enrollees as optional supplementary benefits

B. standard medical-surgical services

C. all of the above

D. mental health and substance abuse services

Correct Answer: C

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AHIP Medical Management (AHM-540) Free Practice Test