Exam Code: AHM-540
Exam Name: Medical Management
Updated:
Q&As: 163
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The case management program director at the Nova Health Plan calculated the program's ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:
Administrative costs for case management ..........$40,000 Actual medical care expenses for patients under case management ..........$680,000 Projected medical care expenses for the same patients without case management ..........$900,000 This information indicates that, for the previous quarter, Nova's ratio of medical expense savings to case
management administrative costs was
A. 0.71/1
B. 0.80/1
C. 5.50/1
D. 1.25/1
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.
The Millway Health Plan received a 15% reduction in the price of a particular pharmaceutical based on the volume of the drug Millway purchased from the manufacturer. This reduction in price is an example of a (rebate / price discount) and (is / is not) dependent on actual provider prescribing patterns.
A. rebate / is
B. rebate / is not
C. price discount / is
D. price discount / is not
Federal laws, such as the Employee Retirement Income Security Act (ERISA), the Balanced Budget Act (BBA) of 1997, and the Health Insurance Portability and Accountability Act (HIPAA), have affected medical management activities by health plans. Consider the following provisions of federal regulations:
Provision 1--Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered treatment and does not allow health plan members to obtain compensatory or punitive damages
Provision 2--Establishes electronic data security standards, which define the security measures that healthcare organizations must take to protect the confidentiality of electronically stored and transmitted patient information From the answer choices below, select the response that correctly identifies the federal laws that include Provision 1 and Provision 2, respectively.
A. Provision 1- ERISA Provision 2- HIPAA
B. Provision 1- HIPAA Provision 2- ERISA
C. Provision 1- BBA of 1997 Provision 2- HIPAA
D. Provision 1- ERISA Provision 2- BBA of 1997
State governments serve as both regulators and purchasers of health plan services. The influence of state governments as purchasers is focused on
A. Medicare and TRICARE programs
B. Medicaid and workers' compensation programs
C. Medicare and Medicaid programs
D. TRICARE and workers' compensation programs
Determine whether the following statement is true or false:
All health plans participating in the Federal Employee Health Benefits Program (FEHBP) are required to use the Consumer Assessment of Health Plans (CAHPS) to measure customer satisfaction.
A. True
B. False
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