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Exam Code: AHM-530
Exam Name: Network Management
One year free update, No help, Full refund!
AHM-530 Real Exams Total Q&A: 202 Questions and Answers
Last Update: 03-23,2015

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NO.1 Dr. Sarah Carmichael is one of several network providers who serve on one of the Apex Health
Plan's organizational committees. The committee reviews cases against providers identified through
complaints and grievances or through clinical monitoring activities. If needed, the committee
formulates, approves, and monitors corrective action plans for providers. Although Apex
administrators and other employees also serve on the committee, only participating providers have
voting rights. The committee that Dr. Carmichael serves on is a
A. Utilization management committee
B. Peer review committee
C. Medical advisory committee
D. Credentialing committee
Answer: B

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NO.2 One true statement about the compensation arrangement known as the case rate system is
that, under this system,
A. Providers stand to gain or lose based on the number and types of treatments used for each case
B. Providers have no incentives to take an active role in managing cost and utilization
C. Payors cannot adjust standard case rates to reflect the severity of the patient's condition or
complications that arise from multiple medical problems
D. Payors have the opportunity to benefit from the provider's cost savings
Answer: A

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NO.3 With respect to contractual provisions related to provider-patient communications,
nonsolicitation clauses prohibit providers from
A. Encouraging patients to switch from one health plan to another
B. Disclosing confidential information about the health plan's reimbursement structure
C. Dispersing confidential financial information regarding the health plan
D. Discussing alternative treatment plans with patients
Answer: A

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NO.4 Under the compensation arrangement that the Falcon Health Plan has with some of its
providers, Falcon holds back 10% of the negotiated payments to these providers in order to offset or
pay for any claims that exceed the budgeted costs for referral or hospital services. If the providers
keep costs within the budgeted amount, Falcon distributes to them the entire amount of money held
back. This way of motivating providers to control costs while providing high-quality, appropriate care
is known as a:
A. Risk pool arrangement
B. Withhold arrangement
C. Cost-shifting arrangement
D. Bonus pool arrangement
Answer: B

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NO.5 With regard to the compensation of dental care providers in a managed dental care system, it is
correct to state that, typically:
A. dental PPOs compensate dentists on a capitated basis
B. group model dental HMOs (DHMOs) compensate general dental practitioners on a salaried basis
C. independent practice association (IPA)-model dental HMOs (DHMOs) capitate general dental
practitioners
D. staff model dental HMOs (DHMOs) compensate dentists on an FFS basis
Answer: C

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NO.6 Health plans typically conduct two types of reviews of a provider's medical records: an
evaluation of the provider's medical record keeping (MRK) practices and a medical record review
(MRR). One true statement about these types of reviews is that:
A. An MRK covers the content of specific patient records of a provider.
B. The NCQA requires an examination of MRK with all of a health plan's office evaluations.
C. An MRR includes a review of the policies, procedures, and documentation standards the provider
follows to create and maintain medical records.
D. The NCQA requires MRR for both credentialing and recredentialing of providers in a health plan's
network.
Answer: A

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NO.7 The Adobe Health Plan complies with all of the provisions of the Newborns' and Mothers'
Health Protection Act (NMHPA) of 1996. Kristen Netzger, an Adobe enrollee, was hospitalized for a
cesarean delivery. Amy Davis, also an Adobe enrollee, was hospitalized for a normal delivery. From
the following answer choices, select the response that indicates the minimum length of time for
which Adobe, under NMHPA, most likely must provide benefits for the hospitalizations of Ms.
Netzger and Ms. Davis.
A. Ms. Netzger = 48 hours Ms. Davis = 48 hours
B. Ms. Netzger = 72 hours Ms. Davis = 72 hours
C. Ms. Netzger = 96 hours Ms. Davis = 48 hours
D. Ms. Netzger = 96 hours Ms. Davis = 72 hours
Answer: C

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NO.8 The Portway Hospital is qualified to receive Medicaid subsidy payments as a disproportionate
share hospital (DHS). The DHS payments that Portway receives are
A. Made for services rendered to specific patients
B. Made with matching state and federal funds
C. Included in the Medicaid capitation payment made to patients' health plans
D. Defined as cost-based reimbursement (CBR) equal to 100% of Portway's reasonable costs of
providing services to Medicaid recipients
Answer: B

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