Free AHM-250 Exam Dumps

Question 36

- (Topic 2)
One way that MCOs involve providers in risk sharing is by retaining a percentage of the providers' payment during a plan year. At the end of the plan year, the MCO may use the amount retained to offset or pay for any cost overruns for referral or hospital

A. withholds
B. usual, customary, and reasonable (UCR) fees
C. risk pools
D. per diems

Correct Answer:A

Question 37

- (Topic 3)
Which of the following is NOT a reason for conducting utilization reviews?

A. Improve the quality and cost effectiveness of patient care
B. Reduce unnecessary practice variations
C. Make appropriate authorization decisions
D. Accommodate special requirements of inpatient care

Correct Answer:D

Question 38

- (Topic 1)
Federal legislation has placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level.
This federal legislation is the

A. Clayton Act
B. Federal Trade Commission Act
C. McCarran-Ferguson Act
D. Sherman Act

Correct Answer:C

Question 39

- (Topic 3)
System classifies hundreds of hospital services based on a number of criteria, such as primary and secondary diagnosis, surgical procedures, age, gender, and the presence of complications.

A. Carve-out
B. DRG
C. Global capitation
D. Partial capitation

Correct Answer:B

Question 40

- (Topic 3)
The following statements are about the underwriting function within a health plan. Select the answer choice containing the correct statement.

A. The underwriting function in a health plan is primarily concerned with ensuring that the group being underwritten does not include any individuals who are likely to have higher than average utilization of medical services.
B. Compared to a health plan with relaxed underwriting requirements, a similar health plan with very strict underwriting requirements can expect to experience increased healthcare costs and to have significantly higher plan enrollment.
C. Typically, a health plan guarantees the premium rate for a group health contract for a period of no more than six months.
D. In order to determine the actual premium to charge a group, a group underwriter typically considers such factors as level of participation, benefits, and the age and gender distribution of group members.

Correct Answer:D