AHM-530 Free Practice Test

- (Topic 2)
In most states, workers’ compensation is first-dollar and last-dollar coverage, which means thatworkers’ compensation programs

1. A. Can place limits on the benefits they will pay for a given claim
2. B. Can deny coverage for work-related illness or injury if the employer is not at fault
3. C. Must pay 100% of work-related medical and disability expenses
4. D. Can hold employers liable for additional amounts that result from court decisions

Correct Answer: C

- (Topic 2)
Reimbursement for prescription drugs and services in a third-party prescription drug plan typically follows one of two approaches: a reimbursement approach or a service approach. One true statement about these approaches is that:

1. A. Payments under the reimbursement method typically are not subject to any copayment or deductible requirements
2. B. Payments under the reimbursement approach are typically based on a structured reimbursement schedule rather than on usual, customary, and reasonable (UCR) charges
3. C. Most major medical plans follow a service approach
4. D. Most current health plan prescription drug plans are service plans

Correct Answer: D

- (Topic 1)
The following statements are about some of the issues surrounding the contractual responsibilities of health plans. Select the answer choice containing the correct statement.

1. A. Typically, health plans are required to pay completed claims within 10 days of submission.
2. B. Health plans typically are prohibited from examining the financial soundness of a self- funded employer plan that relies on the health plan to pay providers for services received by the plan’s members.
3. C. Patient delivery is one of the most significant factors that health plans consider when determining whether provider services should be reimbursed on a capitated or fee-for- service (FFS) basis.
4. D. Health plans require all providers to agree to an exclusive provider contract.

Correct Answer: C

- (Topic 2)
If a member of the Green Health Plan reasonably believes that a provider in Green's provider network was acting as Green's employee or agent while providing negligent care, then the member may have cause to bring action against the health plan. This legal concept is known as vicarious liability. Steps that Green can take to reduce its exposure to vicarious liability claims include:

1. A. Placing restrictions on provider-member communication involving treatment decisions.
2. B. Implementing risk management and quality assurance programs for its provider network.
3. C. Including in its provider agreements and marketing and membership literature a statement that members of the Green provider network are not independent contractors.
4. D. All of the above.

Correct Answer: B

- (Topic 1)
Federal laws—including the Ethics in Patient Referrals Act, the Health Maintenance Organization (HMO) Act of 1973, the Employee Retirement Income Security Act (ERISA), and the Federal Trade Commission Act—have impacted the ways that health plans conduct business. For instance, the Mosaic Health Plan must comply with the following federal laws in order to operate:
Regulation 1: Mosaic must establish a mandated grievance resolution mechanism, including a method for members to address grievances with network providers.
Regulation 2: Mosaic must not allow its providers to refer Medicare and Medicaid patients to entities in which they have a financial or ownership interest.
From the answer choices below, select the response that correctly identifies the federal legislation on which Regulation 1 and Regulation 2 are based.

1. A. Regulation 1 - The Ethics in Patient Referrals Act Regulation 2 - The HMO Act of 1973
2. B. Regulation 1 - The HMO Act of 1973 Regulation 2 - The Ethics in Patient Referrals Act
3. C. Regulation 1 - ERISA Regulation 2 - The Federal Trade Commission Act
4. D. Regulation 1 - The Federal Trade Commission Act Regulation 2 - ERISA

Correct Answer: B