Exam 1: AHM Medical Management

Private employers are key purchasers of health plan services. The following statement(s) can correctly be made about employer expectations about the quality and cost- effectiveness of healthcare services: 1. For both health maintenance organizations (HMOs) and non-HMO plans, employers typically have access to accreditation results and performance measurement reports to help them evaluate the quality of healthcare and service 2. Because of employers concern about the quality and costs of healthcare services available through health plans, direct contracting has become a dominant model among employers who sponsor health benefit programs for their employees

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. Sharmas 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

With respect to the activities of MCO medical directors, it is correct to say that medicaldirectors typically perform all of the following activities EXCEPT

In most health plans, the formulary system is developed and managed by a P&T committee. The ;P&T committee is responsible for;

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. If Ms. Stanley agrees to the generic substitution, she will receive a drug that

The paragraph below contains an incomplete statement. Select the answer choice containingthe term that correctly completes the paragraph.Medical management programs often require the analysis of many types of data and information.__________________ is an automated process that analyzes variables to help detect patterns andrelationships in the data.

The delivery of quality, cost-effective healthcare is a primary goal of both group healthcareand workers' compensation programs. One difference between group healthcare and workers'compensation is that workers' compensation

To see that utilization guidelines are consistently applied, UR programs rely on authorizationsystems. Determine whether the following statement about authorization systems is true or false:IT Certification Guaranteed, The Easy Way!3Instant Download - Best Exam Practice Material - 100% Money Back Guarantee!Get Latest & Valid AHM-540 Exam's Question and Answers from Examstorrent.com. 3 ;http://www.examstorrent.com/ahm-540-exam-dumps-torrent.htmlOnly physicians can make nonauthorization decisions based on medical necessity.

The following statements describe situations in which health plan members have medicalproblems that require care. Select the statement that describes a situation in which self-care mostlikely would not be appropriate.

Health plans communicate proposed performance changes through action statements. Selectthe answer choice containing an action statement that includes all of the required elements.

The following statement(s) can correctly be made about medical management considerations for the Federal Employee Health Benefits Program (FEHBP): 1. FEHBP plan members who have exhausted the health plan's usual appeals process for a disputed decision can request an independent review by the Office of Personnel Management (OPM) 2. All health plans that cover federal employees are required to develop and implement patient safety initiatives

Since its inception, Medicare has undergone a number of changes because of legal andregulatory action. One result of the Balanced Budget Act (BBA) of 1997 has been to

To measure performance for quality management, health plans collect and analyze three typesof data: financial data, clinical data, and customer satisfaction data. The following statement(s) cancorrectly be made about the sources of clinical data:1.Patient surveys are the most widely used source of disease-specific clinical information2.Outcomes research studies sponsored by academic institutions and professional organizations havelimited usefulness for particular health plans or individual providers3.The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys address both physical and mentalhealth status

Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located at a military installation. Ms. Wilson serves as a primary point of contact between enrollees and the TRICARE system and answers enrollees' questions about plan options, eligibility, provider selection, and claims. This information indicates that Ms. Wilson serves as a

Selene Varga is participating in her health plans disease management program for congestive heart failure. Ms. Vargas health status is regularly monitored and managed by a licensed nurse who visits Ms. Varga at her home to administer treatment and assess the need for changes in Ms. Vargas overall care plan. This information indicates that Ms. Varga is participating in the type of disease management program known as a

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. Ways that workers' compensation health plans can help control the costs of job-related injuries and illnesses include

Determine whether the following statement is true or false: The key to successfully managing the quality and cost-effectiveness of healthcare services for Medicaid enrollees is to merge Medicaid recipients into existing plans.

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

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 andMedicare Services (CMS) initiative designed to strengthen health plans' efforts to protect andimprove the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standardsapply to

Many health plans use clinical pathways to help manage the delivery of acute care services to plan members. One true statement about clinical pathways is that they