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AHIP AHM-530 Exam Questions
- Topic 1: Map out how health insurance providers select, contract with, and compensate specialists and health care facilities/ Learn the process for network provider selection
- Topic 2: Recognize special requirements that affect network management for Medicare, Medicaid, and workers’ compensation networks
- Topic 3: Gain a detailed understanding of the scope and organization of the network management function within health insurance provider organizations
- Topic 4: Explore how health insurance providers ensure their provider networks remain adequate to meet member needs/ Understand how network strategies improve access, quality, and cost-effectiveness
- Topic 5: Identify the primary responsibilities and obligations of health insurance providers and health care providers under a provider contract
- Topic 6: Master the essential elements of a contractual relationship between health insurance providers and health care providers
Free AHIP AHM-530 Exam Actual Questions
Note: Premium Questions for AHM-530 were last updated On Dec. 14, 2024 (see below)
When evaluating the success of providers in meeting standards, a health plan must make adjustments for case mix or severity. One true statement about case mix/severity adjustments is that they:
Dr. Leona Koenig removed the appendix of a plan member of the Helium health plan. In order to increase the level of reimbursement that she would receive from Helium, Dr. Koenig submitted to the health plan separate charges for the preoperative physical examination, the surgical procedure, and postoperative care. All of these charges should have been included in the code for the surgical procedure itself. Dr. Koenig's submission is a misuse of the coding system used by health plans and is an example of:
The Medicaid program subsidizes indigent care through payments to disproportionate share hospitals (DSHs). The Preamble Hospital is a DSH. As a DSH, Preamble most likely:
The Foxfire Health Plan, which has 20,000 members, contracts with dermatologists on a contact capitation basis. The contact capitation arrangement has the following features:
Foxfire distributes the money in the contact capitation fund once each quarter and the distribution is based on the point totals accumulated by each dermatologist.
Foxfire's per member per month (PMPM) capitation for dermatology services is $1.
The dermatologist receives 1 point for each new referral that is not classified as a complicated referral and 1.5 points for each new referral that is classified as complicated.
During the first quarter, Foxfire's PCPs made 450 referrals to dermatologists and 100 of these referrals were classified as complicated. One dermatologist, Dr. Shareef Rashad, received 42 of these referrals; 6 of his referrals were classified as complicated. Statements that can correctly be made about Foxfire's contact capitation arrangement include:
The following statement(s) can correctly be made about contracting and reimbursement of specialty care physicians (SCPs):
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