975 お客様のコメント
質問 1：
If a third party is responsible for injuries to a plan member of the Hope Health Plan, then Hope has a contractual right to file a claim for the resulting healthcare costs against the third party. This contractual right to recovery from the third party is known as
A. Coordination of benefits
B. Subrogation
C. Partial capitation
D. Aremedy provision
正解：B
質問 2：
The Justice Health Plan is eligible to submit reportable actions against medical practitioners to the National Practitioner Data Bank (NPDB). Justice is considering whether it should report the following actions to the NPDB: Action 1-A medical malpractice insurer made a malpractice payment on behalf of a dentist in Justice's network for a complaint that was settled out of court.
Action 2-Justice reprimanded a PCP in its network for failing to follow the health plan's referral procedures.
Action 3-Justice suspended a physician's clinical privileges throughout the Justice network because the physician's conduct adversely affected the welfare of a patient.
Action 4-Justice censured a physician for advertising practices that were not aligned with Justice's marketing philosophy.
Of these actions, the ones that Justice most likely must report to the NPDB include Actions
A. 1 and 3 only
B. 1, 2, and 3 only
C. 3 and 4 only
D. 2 and 4 only
正解：A
質問 3：
Assume that the national average cost per covered employee for PPO rental networks is $3 per member per month (PMPM) and that the average monthly healthcare premium PMPM is $300. This information indicates that, if the number of health plan members is 10,000, then the annual network rental cost to the health plan would be:
A. $9,000,000
B. $30,000
C. $360,000
D. $12,000,000
正解：C
質問 4：
From the following answer choices, choose the term that best matches the description.
Members of a physician-hospital organization (PHO) denied membership to a physician solely because the physician has admitting privileges at a competing hospital.
A. Group boycott
B. Concerted refusal to admit
C. Tying arrangements
D. Horizontal division of territories
正解：A
質問 5：
The employees of the Trilogy Company are covered by a typical workers' compensation program. Under this coverage, Trilogy employees are bound by the exclusive remedy doctrine, which most likely:
A. Allows Trilogy to place limits on the amount of coverage payable for a given claim under the workers' compensation program.
B. Requires the employees to accept workers' compensation as their only compensation in cases of work-related injury or illness.
C. Provides the employees with 24-hour coverage.
D. Allows Trilogy to deny benefits for an employee's on-the-job injury or illness, but only if Trilogy is not at fault for the injury or illness.
正解：B
質問 6：
The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline.
Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn's PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn's dermatology services fund for the first quarter was $15,000. During the quarter, Autumn's PCPs made 90 referrals, and 20 of these referrals were classified as complicated.
Autumn's method of reimbursing specialty providers can best be described as a
A. Risk adjustment arrangement
B. Disease-specific arrangement
C. Withhold arrangement
D. Contact capitation arrangement
正解：D
質問 7：
Following statements are about accreditation of health plans:
A. States are required to adopt the model standards developed by the National Association of Insurance Commissioners (NAIC), an organization of state insurance regulators that develops standards to promote uniformity in insurance regulations.
B. Accreditation is an evaluative process in which a health plan undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the federal government or by the state governments.
C. The National Committee for Quality Assurance (NCQA) serves as the primary accrediting agency for most health maintenance organizations (HMOs).
D. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has developed standards that can be used for the accreditation of hospitals, but not for the accreditation of health plan provider networks or health plan plans.
正解：C
質問 8：
The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
Qualitative measures that Azure could use to assess provider performance include an evaluation of how
A. Often the provider refers plan members for ancillary services
B. Effectively the provider communicates with plan members
C. Quickly the provider responds to plan members' inquiries
D. Many plan members visit the provider per month
正解：A
If a third party is responsible for injuries to a plan member of the Hope Health Plan, then Hope has a contractual right to file a claim for the resulting healthcare costs against the third party. This contractual right to recovery from the third party is known as
A. Coordination of benefits
B. Subrogation
C. Partial capitation
D. Aremedy provision
正解：B
質問 2：
The Justice Health Plan is eligible to submit reportable actions against medical practitioners to the National Practitioner Data Bank (NPDB). Justice is considering whether it should report the following actions to the NPDB: Action 1-A medical malpractice insurer made a malpractice payment on behalf of a dentist in Justice's network for a complaint that was settled out of court.
Action 2-Justice reprimanded a PCP in its network for failing to follow the health plan's referral procedures.
Action 3-Justice suspended a physician's clinical privileges throughout the Justice network because the physician's conduct adversely affected the welfare of a patient.
Action 4-Justice censured a physician for advertising practices that were not aligned with Justice's marketing philosophy.
Of these actions, the ones that Justice most likely must report to the NPDB include Actions
A. 1 and 3 only
B. 1, 2, and 3 only
C. 3 and 4 only
D. 2 and 4 only
正解：A
質問 3：
Assume that the national average cost per covered employee for PPO rental networks is $3 per member per month (PMPM) and that the average monthly healthcare premium PMPM is $300. This information indicates that, if the number of health plan members is 10,000, then the annual network rental cost to the health plan would be:
A. $9,000,000
B. $30,000
C. $360,000
D. $12,000,000
正解：C
質問 4：
From the following answer choices, choose the term that best matches the description.
Members of a physician-hospital organization (PHO) denied membership to a physician solely because the physician has admitting privileges at a competing hospital.
A. Group boycott
B. Concerted refusal to admit
C. Tying arrangements
D. Horizontal division of territories
正解：A
質問 5：
The employees of the Trilogy Company are covered by a typical workers' compensation program. Under this coverage, Trilogy employees are bound by the exclusive remedy doctrine, which most likely:
A. Allows Trilogy to place limits on the amount of coverage payable for a given claim under the workers' compensation program.
B. Requires the employees to accept workers' compensation as their only compensation in cases of work-related injury or illness.
C. Provides the employees with 24-hour coverage.
D. Allows Trilogy to deny benefits for an employee's on-the-job injury or illness, but only if Trilogy is not at fault for the injury or illness.
正解：B
質問 6：
The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline.
Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn's PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn's dermatology services fund for the first quarter was $15,000. During the quarter, Autumn's PCPs made 90 referrals, and 20 of these referrals were classified as complicated.
Autumn's method of reimbursing specialty providers can best be described as a
A. Risk adjustment arrangement
B. Disease-specific arrangement
C. Withhold arrangement
D. Contact capitation arrangement
正解：D
質問 7：
Following statements are about accreditation of health plans:
A. States are required to adopt the model standards developed by the National Association of Insurance Commissioners (NAIC), an organization of state insurance regulators that develops standards to promote uniformity in insurance regulations.
B. Accreditation is an evaluative process in which a health plan undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the federal government or by the state governments.
C. The National Committee for Quality Assurance (NCQA) serves as the primary accrediting agency for most health maintenance organizations (HMOs).
D. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has developed standards that can be used for the accreditation of hospitals, but not for the accreditation of health plan provider networks or health plan plans.
正解：C
質問 8：
The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
Qualitative measures that Azure could use to assess provider performance include an evaluation of how
A. Often the provider refers plan members for ancillary services
B. Effectively the provider communicates with plan members
C. Quickly the provider responds to plan members' inquiries
D. Many plan members visit the provider per month
正解：A
Yashiro -
Pass4Testのおかげで無事合格だぁ！！AHM-530この問題集はとてもわかりやすいので、しっかりとした理解に導いてくれるAHIPのAHM-530問題集が合格への最短ルートです。