Free AHM-540: Medical Management Exam Questions and Answers

The Lakeshore Health Plan mails reminders to female members aged 50 to 74 who have not had a mammogram in the past two years. The purpose of the program is to detect breast cancer in its early stages, before symptoms appear. This program is an example of which level of prevention?

• AA. Secondary prevention
• BB. Rehabilitation
• CC. Tertiary prevention
• DD. Primary prevention

Under the original Medicare program, Medicare Part B covers

• AA. managed care coverage through private plans approved by Medicare
• BB. outpatient prescription drug benefits offered through private plans
• CC. inpatient hospital care and skilled nursing facility care that follows a hospital stay
• DD. physician services, outpatient care, and preventive services

Which of the following best describes subacute care?

• AA. Care that is less intensive than acute hospital care but more intensive than traditional nursing facility care
• BB. Nonmedical help with daily living for members whose chronic conditions are stable
• CC. Intensive care for patients with unstable conditions who need continuous physician presence
• DD. Comfort-focused care for members whose life expectancy is estimated at six months or less

Which of the following statements correctly describes concurrent review?

• AA. It evaluates a proposed service before delivery to decide whether the service is covered and medically necessary
• BB. It evaluates the need for continued services while a member is receiving care, such as during an inpatient stay
• CC. It evaluates a member's needs after discharge and arranges services such as home health visits
• DD. It evaluates claims after care has been delivered to identify patterns of overuse or billing errors

The Lakeshore Health Plan has delegated utilization review for its HMO members to Ridgeway Medical Group under a written agreement. Which action is appropriate for Lakeshore to take to oversee the delegated function?

• AA. Transfer accountability for regulatory compliance to Ridgeway once the delegation agreement has been signed
• BB. Approve each of Ridgeway's UR decisions individually before the decision is communicated to the member
• CC. Accept Ridgeway's own accreditation certificate as proof of compliance and omit further review during the contract term
• DD. Review Ridgeway's regular performance reports and audit a sample of its UR files against the standards in the agreement

Walter Park, age 78, is stable after hospital treatment for a hip fracture. He needs daily nursing care for wound management and daily physical therapy, but he does not need the intensity of services provided in an acute care hospital, and he cannot manage safely at home. His case manager is arranging the next level of care. Which setting is most appropriate?

• AA. An adult day care center
• BB. A skilled nursing facility
• CC. A long-term acute care hospital
• DD. A hospice program

Which of the following is an example of misuse of healthcare services?

• AA. A member with an uncomplicated backache has an MRI that is not supported by clinical guidelines
• BB. A member postpones a recommended cancer screening because of out-of-pocket cost
• CC. A member with persistent asthma is not prescribed a controller medication
• DD. A member takes a prescribed drug that interacts dangerously with another medication the member already takes

The Pinecrest Health Plan intends to delegate the credentialing of its network physicians to Harlan Health System. Which step should Pinecrest take FIRST?

• AA. Transfer Pinecrest's existing credentialing files to Harlan so renewals can begin
• BB. Notify the state insurance department that credentialing accountability now rests with Harlan
• CC. Execute the delegation agreement and schedule the first audit for twelve months later
• DD. Conduct a pre-delegation assessment of Harlan's credentialing policies, staffing and processes

The Ridgefield Health Plan mails reminder letters each year to women aged 50 to 74 who have no breast symptoms and covers screening mammography for them at no cost share. The goal is to detect breast cancer at an early, more treatable stage. This program is best classified as

• AA. Primary prevention
• BB. Health promotion
• CC. Secondary prevention
• DD. Tertiary prevention

The Medicaid program is financed by

• AA. Employers and enrollees through premiums and payroll contributions
• BB. The federal government alone through Social Security payroll taxes
• CC. Federal and state governments through matching funds
• DD. State governments alone through general revenue and provider taxes