ahip ahm-520 practice test

Under the doctrine of corporate negligence, a health plan and its physician administrators may be
held directly liable to patients or providers for failing to investigate adequately the competence of
healthcare providers whom it employs or with whom it contracts, particularly where the health plan
actually provides healthcare services or restricts the patient's/enrollee's choice of physician.

• A. True
• B. False

The Eagle health plan wants to limit the possibility that it will be held vicariously liable for the
negligent acts of providers. Dr. Michael Chan is a member of an independent practice association
(IPA) that has contracted with Eagle. One step that Eagle could take in order to limit its exposure
under the theory of vicarious liability is to

• A. Supply Dr. Chan with office space
• B. Employ nurses, laboratory technicians, and therapists to support Dr.Chan
• C. Be responsible for keeping Dr. Chan's medical records updated
• D. Ensure that documents provided to Dr. Chan's patients describe him as an independent practitioner

Rasheed Azari, the risk manager for the Tower health plan, is attempting to work with providers in
the organization in order to reduce the providers' exposure related to utilization review. Mr. Azari is
considering advising the providers to take the following actions:
1-Allow Tower's utilization management decisions to override a physician's independent medical
judgment
2-Support the development of a system that can quickly render a second opinion in case of
disagreement surrounding clinical judgment
3-Inform a patient of any issues that are being disputed relative to a physician's recommended
treatment plan and Tower's coverage decision
Of these possible actions, the ones that are likely to reduce physicians' exposures related to
utilization review include actions

• A. 1, 2, and 3
• B. 1 and 2 only
• C. 1 and 3 only
• D. 2 and 3 only

The following statements are about risk management in health plans. Select the answer choice
containing the correct response.

• A. Risk management is especially important to health plans because the Employee Retirement Income Security Act of 1974 (ERISA) allows plan members to recover punitive damages from healthcare plans.
• B. With regard to the relative risk for health plan structures based upon the degree of influence and relationships that health plans maintain with their providers, preferred provider organizations (PPOs) typically have a higher risk than do group HMOs and staff HMOs.
• C. Although there are clear risks associated with the provision of healthcare services and coverage decisions surrounding that care, the bulk of risk in health plans is associated with a health plan's benefit administration and contracting activities.
• D. A health plan generally structures its risk management process around loss reduction techniques and loss transfer techniques.

Several federal agencies establish rules and requirements that affect health plans. One of these
agencies is the Department of Labor (DOL), which is primarily responsible for _________.

• A. Issuing regulations pertaining to the Health Insurance Portability and Accountability Act (HIPAA) of 1996
• B. Administering the Medicare and Medicaid programs
• C. Administering ERISA, which imposes various documentation, appeals, reporting, and disclosure requirements on employer group health plans
• D. Administering the Federal Employees Health Benefits Program (FEHBP), which provides voluntary health insurance coverage to federal employees, retirees, and dependents

The Atoll Health Plan must comply with a number of laws that directly affect the plan's contracts.
One of these laws allows Atoll's plan members to receive medical services from certain specialists
without first being referred to those specialists by a primary care provider (PCP). This law, which
reduces the PCP's ability to manage utilization of these specialists, is known as _________.

• A. A due process law
• B. An any willing provider law
• C. A direct access law
• D. A fair procedure law

Mandated benefit laws are state or federal laws that require health plans to arrange for the financing
and delivery of particular benefits. Within a market, the implementation of mandated benefit laws is
likely to cause __________.

• A. A reduction in the number of self-funded healthcare plans
• B. An increase in the cost to the health plans
• C. A reduction in the size of the provider panels of health plans
• D. A reduction in the uniformity among the healthcare plans of competing health plans

The physicians who work for the Sunrise Health Plan, a staff model HMO, are paid a salary that is not
augmented with another type of incentive plan. Compared to the use of a traditional reimbursement
method, Sunrise's use of a salary reimbursement method is more likely to

• A. Encourage Sunrise's physicians to perform services that are not medically necessary
• B. Completely eliminate service risk for Sunrise's physicians
• C. Decrease Sunrise's liability for any negligent acts of the physicians in the plan's network of providers
• D. Help stabilize expenses for Sunrise

The Acorn Health Plan uses a resource-based relative value scale (RBRVS) to help determine the
reimbursement amounts that Acorn should make to providers who are compensated under an FFS
system. With regard to the advantages and disadvantages to Acorn of using RBRVS, it can correctly be
stated that

• A. An advantage of using RBRVS is that it can assist Acorn in developing reimbursement schedules for various types of providers in a comprehensive healthcare plan
• B. An advantage of using RBRVS is that it puts providers who render more medical services than necessary at financial risk for this overutilization
• C. A disadvantage of using RBRVS is that it will be difficult for Acorn to track treatment rates for the health plan's quality and cost management functions
• D. A disadvantage of using RBRVS is that it rewards procedural healthcare services more than cognitive healthcare services

Health plans sometimes use global fees to reimburse providers. Health plans would use this method
of provider reimbursement for all of the following reasons EXCEPT that global fees

• A. Eliminate any motivation the provider may have to engage in churning
• B. Transfer some of the risk of overutilization of care from the health plan to the providers
• C. Eliminate the practice of upcoding within specific treatments
• D. Reward providers who deliver cost-effective care