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AHIP AHM-520 Exam
Health Plan Finance and Risk Management (Page 17 )

Updated On: 9-Feb-2026
Page 8 of 44
PDF with 215 Questions

Reconciliation is the process by which a health plan assesses providers' performance relative to contractual terms and reimbursement.

With regard to this process, it can correctly be stated that

  1. A reconciliation typically includes payment to the providers of any withholds or bonuses due to them
  2. A health plan typically should conduct a reconciliation immediately after the evaluation period has ended
  3. Most agreements between health plans and providers require reconciliations to be performed quarterly
  4. A health plan typically should not conduct reconciliation for a provider until the plan has received all claims or other documentation of services that the physician provided during the evaluation period

Answer(s): A



With regard to capitation arrangements for hospitals, it can correctly be Back to Top stated that

  1. The most common reimbursement method for hospitals is professional services capitation
  2. Most jurisdictions prohibit hospitals and physicians from joining together to receive global capitations that cover institutional services provided by the hospitals
  3. A health plan typically can capitate a hospital for outpatient laboratory and X-ray services only if the health plan also capitates the hospital for inpatient care
  4. Many hospitals have formed physician hospital organizations (PHOs), hospital systems, or integrated delivery systems (IDSs) that can accept global capitation payments from health plans

Answer(s): D



The Newfeld Hospital has contracted with the Azalea Health Plan to provide inpatient services to Azalea's enrolled members. The contract calls for Azalea to provide specific stop-loss coverage to Newfeld once Newfeld's treatment costs reach $20,000 per case and for Newfeld to pay 20% of the next $50,000 of expenses for this case. After Newfeld's treatment costs on a case reach $70,000, Azalea reimburses the hospital for all subsequent treatment costs.

One true statement about this specific stop-loss coverage is that

  1. The carrier is Newfeld
  2. The attachment point is $20,000
  3. The shared-risk corridor is between $0 and $70,000
  4. This coverage can also be activated when the total covered medical expenses generated by the hospitalizations of Azalea plan members reach a specified level

Answer(s): B



The Newfeld Hospital has contracted with the Azalea Health Plan to provide inpatient services to Azalea's enrolled members. The contract calls for Azalea to provide specific stop-loss coverage to Newfeld once Newfeld's treatment costs reach $20,000 per case and for Newfeld to pay 20% of the next $50,000 of expenses for this case. After Newfeld's treatment costs on a case reach $70,000, Azalea reimburses the hospital for all subsequent treatment costs.

The maximum amount for which Newfeld is at risk for any one Azalea plan member's treatment costs is

  1. $10,000
  2. $14,000
  3. $30,000
  4. $34,000

Answer(s): C



The Sanford Group, a provider group, entered into a risk contract with a health plan. Sanford has purchased aggregate stop-loss coverage with an attachment point of 115% of the group's predicted healthcare costs of $2,000,000 for the year. Sanford has a copayment of 10% for any costs above the attachment point. If Sanford's actual costs for the year are $2,800,000, then, according to the terms of the aggregate stop-loss agreement, the amount that Sanford is responsible for is

  1. $2,080,000
  2. $2,300,000
  3. $2,350,000
  4. $2,380,000

Answer(s): C






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