AHIP AHM-510 問題集

質問 1：
Arthur Dace, a plan member of the Bloom Health Plan, tried repeatedly over an extended period to schedule an appointment with Dr. Pyle, his primary care physician (PCP). Mr. Dace informally surveyed other Bloom plan members and found that many people were experiencing similar problems getting an appointment with this particular provider. Mr. Dace threatened to take legal action against Bloom, alleging that the health plan had deliberately allowed a large number of patients to select Dr. Pyle as their PCP, thus making it difficult for patients to make appointments with Dr. Pyle.
Bloom recommended, and Mr. Dace agreed to use, an alternative dispute resolution (ADR) method that is quicker and less expensive than litigation. Under this ADR method, both Bloom and Mr. Dace presented their evidence to a panel of medical and legal experts, who issued a decision that Bloom's utilization management practices in this case did not constitute a form of abuse. The panel's decision is legally binding on both parties.
This information indicates that Bloom resolved its dispute with Mr. Dace by using an ADR method known as:
A. An ethics committee
B. Arbitration
C. Corporate risk management
D. An ombudsman program
正解：B

質問 2：
In developing its corporate strategies, the Haven Health Plan decided to implement a growth strategy that is focused on increasing the percentage of preventive health office visits from its current plan members. To accomplish this objective, Haven will send a direct mail kit to existing plan members to remind them of the variety of preventive health services that Haven currently offers, including physical exams, cholesterol tests, and mammograms. This information illustrates Haven's use of
A. An integrated growth strategy known as product development
B. A diversified growth strategy known as market penetration
C. An integrated growth strategy known as market development
D. An intensive growth strategy known as market penetration
正解：D

質問 3：
One federal law amended the Social Security Act to allow states to set their own qualification standards for HMOs that contracted with state Medicaid programs and revised the requirement that participating HMOs have an enrollment mix of no more than 50% combined Medicare and Medicaid members.
This act, which was the true stimulus for increasing participation by health plans in Medicaid, is called the
A. Federal Employees Health Benefits Act of 1958 (FEHB Act)
B. Employee Retirement Income Security Act of 1974 (ERISA)
C. Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
D. Omnibus Budget Reconciliation Act of 1981 (OBRA-81)
正解：D

質問 4：
SoundCare Health Services, an MCO, recently conducted a situation analysis. One step in this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activity provided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detecting violations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.
By definition, the activity that SoundCare conducted when it examined its strengths, weaknesses, and capabilities is known as
A. An internal assessment
B. A community analysis
C. An environmental forecast
D. An environmental analysis
正解：A

質問 5：
Determine whether the following statement is true or false:
Although most-favored-nation (MFN) clauses in contracts between health plans and healthcare providers are not per se illegal, they should be reviewed under the rule of reason analysis for antitrust purposes.
A. False, because MFN clauses involve decisions by providers concerning the level of fees to charge, and thus they are per se illegal.
B. True, because the Federal Trade Commission (FTC) ruled that MFN clauses are not per se illegal and the FTC encourages health plans to include them in provider contracts.
C. False, because MFN clauses are not per se illegal, and thus they are exempt from antitrust laws and regulation by the FTC.
D. True, because although MFN clauses are not per se illegal, they violate antitrust laws if they have a predatory purpose and an anticompetitive effect.
正解：D

質問 6：
SoundCare Health Services, a health plan, recently conducted a situation analysis. One step in this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activity provided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detectingviolations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.
With respect to the Federal Sentencing Guidelines, actions that SoundCare should take in developing its compliance program include
A. Holding management accountable for the misconduct of their subordinates
B. Assigning a high-level member of management to the position of compliance coordinator or administrator
C. Creating a system through which employees and other agents can report suspected misconduct without fear of retribution
D. All of the above
正解：D