AHIP AHM-530 問題集

質問 1：
The following statements are about the inclusion of unified pharmacy benefits in health plan healthcare packages. Select the answer choice containing the correct statement.
A. Under a unified pharmacy benefit, an health plan cannot use mail-order services to provide drugs to its members.
B. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs make drug therapy interventions for plan members more difficult.
C. When pharmacy benefits management is incorporated into an health plan's operations as a unified benefit, the health plan establishes pharmacy networks, but a pharmacy benefits management (PBM) company manages their operations.
D. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs typically give health plans more control over patient access to prescription drugs.
正解：D

質問 2：
Some states have enacted any willing provider laws. From the perspective of the health plan industry, one drawback of any willing provider laws is that they often result in a reduction of a plan's
A. Premium rates
B. Number of primary care providers (PCPs)
C. Number of specialists and ancillary providers
D. Ability to monitor utilization
正解：D

質問 3：
In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.
In most states, a health plan can be held responsible for a provider's negligent malpractice. This legal concept is known as (vicarious liability / risk sharing). One step that health plans can take to reduce their exposure to malpractice lawsuits is to state in health plan-provider agreements,marketing collateral, and membership literature that the providers are (employees of the health plan / independent contractors).
A. Vicarious liability / independent contractors
B. Vicarious liability / employees of the health plan
C. Risk sharing / employees of the health plan
D. Risk sharing / independent contractors
正解：A

質問 4：
Before or during the orientation process, health plans generally provide new network providers with a provider manual. One of the primary purposes of the provider manual is to
A. Provide feedback to providers regarding their performance
B. Provide a directory of contracted providers
C. Reinforce and document contractual provisions
D. Help providers and their staffs develop methods of improving the operation of their practices
正解：C

質問 5：
The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that
she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan member for covered services is known as:
A. An indemnification clause
B. Atermination with cause clause
C. Acorrective action clause
D. Ahold-harmless clause
正解：D