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AHM-250
Healthcare Management: An Introduction Questions and Answers

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Viewing page 7 out of 11 pages

Viewing questions 61-70 out of questions

Questions # 61:

Janet Riva is covered by a traditional indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan.

Options:

$1,750

$1,800

$2,000

$2,250

Answer

Questions # 62:

Most contracts between health plans and providers contain a provision which forbids providers from seeking compensation from patients if the health plan fails to compensate the provider because of insolvency or for any other reason. Such a provision is kn

Options:

due process provision

cure provision

hold-harmless provision

risk-sharing provision

Answer

Questions # 63:

Katrina Lopez is a claims analyst for a health plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Ms. Lopez reviewed a health claim for answers to the following questions:

Question A -

Options:

A, B, C, and D

A, B, and D only

B, C, and D only

A and C only

Answer

Questions # 64:

The Advantage Health Plan recently added the following features to its member services program:

1. IVR

2. Active member outreach program

3. Advantage's member services staffing needs are likely to increase as a result of

Options:

1 & 2

Neither 1 nor 2

Answer

Questions # 65:

Some states mandate that an independent enrollment broker or benefits counselor contractor selected by the state must manage enrollment of the eligible Medicaid population into managed care. In other states a health plan can engage independent brokers and

Options:

Many states have regulations that prohibit health plans from using door-to-door and/or telephone solicitation to market health plan products to the Medicaid population.

Health plans are never allowed to medically underwrite individual market customers who are under age 65.

To promote a health plan product to the individual market, health plans typically use captive agents who give sales presentations to potential customers, rather than using promotion tools such as direct mail, telemarketing, or advertising.

Health plans typically are allowed to medically underwrite all individual market customers who are covered by Medicare and can refuse to cover such customers.

Answer

Questions # 66:

Medicare is the federal government program established under Title XVIII of the Social Security Act of 1965 to provide hospital, medical and other covered benefits to elderly and disabled persons. Medicare is available for:

Options:

Persons age 63 or older.

Persons with qualifying disabilities (over the age of 63)

Persons with end-stage renal disease (ESRD)

Low income individuals

Answer

Questions # 67:

Managed behavioral health organizations (MBHOs) use several strategies to manage the delivery of behavioral healthcare services. The following statements are about these strategies.

Select the answer choice that contains the correct statement.

Options:

MBHOs generally provide benefits for mental health services but not for chemical dependency services.

The level of care needed to treat behavioral disorders is the same for all patients and all disorders.

By using outpatient treatment more extensively, MBHOs have decreased the use of costly inpatient therapies.

PCP gatekeeper systems for behavioral healthcare generally result in more accurate diagnoses, more effective treatment, and more efficient use of resources than do centralized referral systems.

Answer

Questions # 68:

In the United States, the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the TRICARE health plan. One true statement about TRICARE is that:

Options:

Active duty military personnel are automatically considered enrolled in TRICARE Prime

TRICARE covers inpatient and outpatient services, physician and hospital charges, and medical supplies, but not mental health services.

TRICARE enrollees are not entitled to appeal authorization or coverage decisions

Hospitals participating in the TRICARE program are exempt from JCAHO accreditation and Medicare certification.

Answer

Questions # 69:

The data evaluation stage of utilization review (UR) includes both administrative reviews and medical reviews. One true statement about these types of reviews is that:

Options:

An administrative review must be conducted by a health plan staff member who is a medical professional.

The primary purpose of an administrative review is to evaluate the appropriateness of a proposed medical service.

UR staff members typically conduct a medical review of a proposed medical service before they conduct an administrative review for that same service.

One purpose of a medical review is to evaluate the medical necessity of a proposed medical service.

Answer

Questions # 70:

Merle Spencer has coverage under both Medicare Part A and Medicare Part B. Ms. Spencer recently was hospitalized for chest pains, and she incurred charges for:

The cost of hospitalization for two days

Diagnostic tests performed in the hospital

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