AHIP AHM-530 問題集

質問 1：
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. 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.
C. Provides the employees with 24-hour coverage.
D. Requires the employees to accept workers' compensation as their only compensation in cases of work-related injury or illness.
正解：D

質問 2：
In health plan pharmacy networks, service costs consist of two components: costs for services associated with dispensing prescription drugs and costs for cognitive services. Cognitive services typically include:
A. making generic substitutions of drugs
B. providing patient monitoring
C. counseling patients about prescriptions
D. switching prescription drugs to preferred drugs
正解：C

質問 3：
During the credentialing process, a health plan verifies the accuracy of information on a prospective network provider's application. One true statement regarding this process is that the health plan
A. must limit any evaluations of a prospective provider's office to an assessment of quantitative factors, such as the number of double-booked appointments a physicianaccepts at the end of each day
B. must complete the credentialing process before a provider signs the network contract or must include in the signed document a provision that the final contract is contingent upon the completion of the credentialing process
C. has a legal right to access a prospective provider's confidential medical records at any time
D. is prohibited by law from conducting primary verification of such data as a prospective provider's scope of medical malpractice insurance coverage and federal tax identification number
正解：B

質問 4：
Under the compensation arrangement that the Falcon Health Plan has with some of its providers, Falcon holds back 10% of the negotiated payments to these providers in order to offset or pay for any claims that exceed the budgeted costs for referral or hospital services. If the providers keep costs within the budgeted amount, Falcon distributes to them the entire amount of money held back. This way of motivating providers to control costs while providing high-quality, appropriate care is known as a:
A. Bonus pool arrangement
B. Cost-shifting arrangement
C. Withhold arrangement
D. Risk pool arrangement
正解：C

質問 5：
The following situations illustrate violations of federal antitrust laws:
Situation A Two HMOs split a large employer group by agreeing to let one HMO market to some company employees and to let the second HMO market to different company employees.
Situation B Members of a physician-hospital organization (PHO) that has significant market share jointly agreed to exclude a physician from joining the PHO solely because that physician has admitting privileges at a competing hospital.
From the following answer choices, select the response that best identifies the types of violations illustrated by these situations:
A. Situation A: horizontal division of territories; Situation B: exclusive arrangement
B. Situation A: exclusive arrangement; Situation B: tying arrangement
C. Situation A: exclusive arrangement; Situation B: group boycott
D. Situation A: horizontal division of territories; Situation B: group boycott
正解：D