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AHM-250 - Healthcare Management: An Introduction

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AHM-250 Questions and Answers

Question # 1

Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.

A.

The Serenity Healthcare Organization requires a plan member or the provider in charge of the member's care to obtain authorization for inpatient care before the member is admitted to the hospital.

B.

UR nurses employed by the Friendship Health Plan monitor length of stay to identify factors that might contribute to unnecessary hospital days.

C.

The Optimum Health Group evaluates the medical necessity and appropriateness of proposed services and intervenes, if necessary, to redirect care to a more appropriate care setting.

D.

The Axis Medical Group examines provider practice patterns to identify areas in which services are being underused, overused, or misused and designs strategies to prevent inappropriate utilization in the future.

Question # 2

A health plan may use one of several types of community rating methods to set premiums for a health plan. The following statements are about community rating. Select the answer choice containing the correct statement.

A.

Standard (pure) community rating is typically used for large groups because it is the most competitive rating method for large groups.

B.

Under standard (pure) community rating, a health plan charges all employers or other group sponsors the same dollar amount for a given level of medical benefits or health plan, without adjusting for factors such as age, gender, or experience.

C.

In using the adjusted community rating (ACR) method, a health plan must consider the actual experience of a group in developing premium rates for that group.

D.

The Centers for Medicare and Medicaid Services (CMS) prohibits health plans that assume Medicare risk from using the adjusted community rating (ACR) me

Question # 3

In 1999, the United States Congress passed the Financial Services Modernization Act, which is referred to as the Gramm-Leach-Bliley (GLB) Act. The following statement(s) can correctly be made about this act:

A.

The GLB Act allows convergence among the transaction

B.

A only

C.

Both A and B

D.

B only

E.

Neither A nor B

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