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Free AHM-520 Exam Braindumps (page: 5)

Page 4 of 55
PDF with 215 Questions

Rasheed Azari, the risk manager for the Tower health plan, is attempting to work with providers in the organization in order to reduce the providers' exposure related to utilization review. Mr. Azari is considering advising the providers to take the following actions:
1-Allow Tower's utilization management decisions to override a physician's independent medical judgment
2-Support the development of a system that can quickly render a second opinion in case of disagreement surrounding clinical judgment
3-Inform a patient of any issues that are being disputed relative to a physician's recommended treatment plan and Tower's coverage decision

Of these possible actions, the ones that are likely to reduce physicians' exposures related to utilization review include actions

  1. 1, 2, and 3
  2. 1 and 2 only
  3. 1 and 3 only
  4. 2 and 3 only

Answer(s): D



The following statements are about risk management in health plans. Select the answer choice containing the correct response.

  1. Risk management is especially important to health plans because the Employee Retirement Income Security Act of 1974 (ERISA) allows plan members to recover punitive damages from healthcare plans.
  2. With regard to the relative risk for health plan structures based upon the degree of influence and relationships that health plans maintain with their providers, preferred provider organizations (PPOs) typically have a higher risk than do group HMOs and staff HMOs.
  3. Although there are clear risks associated with the provision of healthcare services and coverage decisions surrounding that care, the bulk of risk in health plans is associated with a health plan's benefit administration and contracting activities.
  4. A health plan generally structures its risk management process around loss reduction techniques and loss transfer techniques.

Answer(s): D



Several federal agencies establish rules and requirements that affect health plans. One of these agencies is the Department of Labor (DOL), which is primarily responsible for _________.

  1. Issuing regulations pertaining to the Health Insurance Portability and Accountability Act (HIPAA) of
  2. Administering the Medicare and Medicaid programs
  3. Administering ERISA, which imposes various documentation, appeals, reporting, and disclosure requirements on employer group health plans
  4. Administering the Federal Employees Health Benefits Program (FEHBP), which provides voluntary health insurance coverage to federal employees, retirees, and dependents

Answer(s): C



The Atoll Health Plan must comply with a number of laws that directly affect the plan's contracts. One of these laws allows Atoll's plan members to receive medical services from certain specialists without first being referred to those specialists by a primary care provider (PCP). This law, which reduces the PCP's ability to manage utilization of these specialists, is known as _________.

  1. A due process law
  2. An any willing provider law
  3. A direct access law
  4. A fair procedure law

Answer(s): C






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