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AHIP AHM-520 Exam Questions
Health Plan Finance and Risk Management (Page 6 )

Updated On: 26-Apr-2026
Page 6 of 44
PDF with 215 Questions

The reimbursement arrangement that Dr. Caroline Monroe has with the Exmoor Health Plan includes a typical withhold arrangement. One true statement about this withhold arrangement is that, for a given financial period,

  1. Dr. Monroe and Exmoor are equally responsible for making up the difference if cost overruns exceed the amount of money withheld
  2. Exmoor most likely distributes to Dr. Monroe the entire amount withheld from her if her costs are below the amount budgeted for the period
  3. Exmoor pays Dr. Monroe at the end of the period an amount over and above her usual reimbursement, and this amount is based on the performance of the plan as a whole
  4. Exmoor most likely withholds between 3% and 5% of Dr. Monroe's total reimbursement

Answer(s): B



The following statements are about various reimbursement arrangements that health plans have with hospitals. Select the answer choice containing the correct statement.

  1. A sliding scale per-diem charges arrangement differs from a sliding scale discount on charges arrangement in that only a sliding scale per-diem charges arrangement is based on total volume of admissions and outpatient procedures.
  2. Under a typical reimbursement arrangement that is based on diagnosis related groups (DRGs), if the payment amount is fixed on the basis of diagnosis, then any reduction in costs resulting from a reduction in days will go to the health plan rather than to the hospital.
  3. A negotiated straight per-diem charge requires payment of a single charge for a day in the hospital, regardless of any actual charges or costs incurred during the hospital stay.
  4. A straight discount on charges arrangement is the most common reimbursement method in markets with high levels of health plans.

Answer(s): C



Health plans seeking to provide comprehensive healthcare plans must contract with a variety of providers for ancillary services. One characteristic of ancillary services is that

  1. Physician behavior typically does not impact the utilization rates for these services
  2. Package pricing is the preferred reimbursement method for ancillary service providers
  3. These services include physical therapy, behavior therapy, and home healthcare, but not diagnostic services such as laboratory tests
  4. Few plan members seek these services without first being referred to the ancillary provider by a physician

Answer(s): D



In order to calculate a simple monthly capitation payment, the Argyle Health Plan used the following information:
The average number of office visits each member makes in a year is two The FFS rate per office visit is $55
The member copayment is $5 per office visit
The reimbursement period is one month

Given this information, Argyle would correctly calculate that the per member per month (PMPM) capitation rate should be

  1. $4.17
  2. $8.33
  3. $9.17
  4. $10.00

Answer(s): B



The provider contract that Dr. Timothy Meyer, a pediatrician, has with the Cardigan health plan states that Cardigan will compensate him under a capitation arrangement. However, the contract also includes a typical low enrollment guarantee provision. Statements that can correctly be made about this arrangement include that the low enrollment guarantee provision most likely:

A Causes Dr. Meyer's capitation contract with Cardigan to transfer more risk to him than the contract otherwise would transfer
B) Specifies that Cardigan will pay Dr. Meyer under an arrangement other than capitation until a specified number of children covered by the plan use him as their PCP

  1. Both A and B
  2. A only
  3. B only
  4. Neither A nor B

Answer(s): C



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