Question 1

In a fee-for-service (FFS) reimbursement method, providers are paid per treatment or per service that they provide.One typical benefit of FFS reimbursement is that it:

Options :

A : Is highly effective in preventing excessive services that take the form of churning, unbundling, and upcoding

B : Provides physicians who attempt to control costs with a higher rate of compensation than is provided to physicians who make the effort to control costs

C : Is relatively easy to initiate, especially in markets where managed care penetration is low

D : Guards against the practice of defensive medicine

Answer: B

Question 2

With regard to the financial statements prepared by health plans, it can correctly be stated that:

Options :

A : both for-profit, publicly owned health plans and not-for-profit health plans are required by law to provide all interested parties with an annual report

B : a health plan-s annual report typically includes an independent auditor-s report and notes to the financial statements

C : any health plan that owns more than 20% of the stock of a subsidiary company must compile the financial statements for the health plan-s annual report on a consolidated basis

D : a health plan typically must prepare the financial statements included in its annual report according to SAP

Answer: B

Question 3

The following statements illustrate the use of different rating methods by health plans: The Dover health plan established rates for small groups by using a rating method which requires that the average premium in each group cannot be more than 120% of the average premium for any other group. Under this method, all members of each group pay the same premium, which is based on the experience of the group.Under the rating method used by the Rolling Hills health plan, the health plan calculates the ratio of a group's experience to the group's historical manual rate. Rolling Hills then multiplies this ratio by the group's future manual rate. Rolling Hills cannot consider the group's experience in determining premium rates. From the following answer choices, select the response that correctly indicates the rating methods used by Dover and Rolling Hills.

Options :

A : Dover = modified community ratingRolling Hills = factored rating

B : Dover = modified community ratingRolling Hills = adjusted community rating (ACR)

C : Dover = community rating by class (CRC)Rolling Hills = factored rating

D : Dover = community rating by class (CRC)Rolling Hills = adjusted community rating (ACR)

Answer: D

Question 4

Julio Benini is eligible to receive healthcare coverage through a health plan that is under contract to his employer. Mr. Benini is seeking coverage for the following individuals:

Elena Benini, his wife -

Maria Benini, his 18-year-old unmarried daughter

Johann Benini, his 80-year-old father who relies on Julio for support and maintenance

The health plan most likely would consider that the definition of a dependent, for purposes of healthcare coverage, applies to:

Options :

A : Elena, Maria, and Johann

B : Elena and Maria only

C : Elena only

D : Maria only

Answer: B

Question 5

The Marble Health Plan sets aside a PMPM amount for each specialty.

When a PCP in Marble's provider network refers a Marble plan member to a specialist and the specialist provides medical services to the member, the specialist begins to receive a share of those funds on a monthly basis. Marble determines the monthly payment for each specialist by dividing the number of active patients for that specialty by the total specialty pool for that month.

This form of payment, which is similar to a case rate, is known as:

Options :

A : Referral circle capitation

B : Risk pod capitation

C : Contact capitation

D : Retrospective reimbursement capitation

Answer: C

Free AHM-520 Mock Exam – Practice Online Confidently

Buying Options: