Free AHM-540: Medical Management Exam Questions and Answers

Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services

• AA. must be offered as separate supplemental benefits or separate products
• BB. lack clinical trials to evaluate their safety and effectiveness
• CC. are not covered by state or federal consumer protection statutes
• DD. focus on a specific illness, injury, or symptom rather than on the whole body

The Medicaid population can be divided into subgroups based on their relative size and the costs of providing benefits. From the answer choices below, select the response that correctly identifies the subgroups that represent the largest percentages of the total Medicaid population and of total Medicaid expenditures. Largest % of Medicaid Population- Largest % of Medicaid Expenditures-

• AA. Largest % of Medicaid Population-dual eligibles Largest % of Medicaid Expenditures- children and low-income adults
• BB. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for Medicare Largest % of Medicaid Expenditures-dual eligibles
• CC. Largest % of Medicaid Population-children and low-income adults Largest % of Medicaid Expenditures-chronically ill or disabled individuals not eligible for Medicare
• DD. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for Medicare Largest % of Medicaid Expenditures-children and low-income adults

Breanna Osborn is a case manager for a regional health plan. One component of Ms. Osborn’s job is the collection and evaluation of medical, financial, social, and psychosocial information about a member’s situation. This component of Ms. Osborn’s job is known as

• AA. case identification
• BB. case management planning
• CC. healthcare coordination
• DD. case assessment

The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph. Definitions of quality healthcare vary; however, four dimensions are essential to quality healthcare services. _____ is the quality dimension indicating that services result in the best care for a given cost or the lowest cost for a given level of care.

• AA. Accessibility
• BB. Effectiveness
• CC. Acceptability
• DD. Efficiency

The following statement(s) can correctly be made about the characteristics of peer review: * 1.Peer review is applicable to either single episodes of care or to entire programs of care * 2.Most peer review is conducted concurrently * 3.Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services furnished to Medicare and Medicaid recipients enrolled in health plans

• AA. All of the above
• BB. 1 and 2 only
• CC. 1 and 3 only
• DD. 2 and 3 only

The following statements are about health plans’ development of medical policies. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• AA. Technology assessment is applicable only to medical policy development for new medical procedures, devices, drugs, and tests.
• BB. Technology assessment provides the scientific rationale for the medical policy section that specifies when a medical service is appropriate and when it is not.
• CC. The medical policy development process includes both a clinical and an operational review of a proposed medical policy.
• DD. The decision to accept or reject a proposed medical policy often depends on how a new technology compares to currently used interventions.

This agency oversees the Federal Employee Health Benefits Program (FEHBP).

• AA. Health Resources and Services Administration (HRSA)
• BB. Office of Personnel Management (OPM)
• CC. Department of Health and Human Services (HHS)
• DD. Department of Justice (DOJ)

Health plan performance measures include structure measures, process measures, and outcome measures. The following statements are about the characteristics of these three types of performance measures. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• AA. The most widely used structure measures relate to physician education and training.
• BB. One advantage of structure measures over process measures is that structures are often linked directly to healthcare outcomes.
• CC. Process measures are useful in identifying underuse, overuse, and inappropriate use of services.
• DD. One disadvantage of outcome measures is that they can be influenced by factors outside the control of the health plan.

The following statements are about the characteristics of a utilization review (UR) program. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• AA. A primary goal of UR is to address practice variations through the application of uniform standards and guidelines.
• BB. UR evaluates whether the services recommended by a member’s provider are covered under the benefit plan.
• CC. UR recommends the procedures that providers should perform for plan members.
• DD. A health plan’s UR program is usually subject to review and approval by the state insurance and/or health departments.

Determine whether the following statement is true or false: Participation in disease management programs is currently voluntary.

• AA. True
• BB. False