AHIP Healthcare Management: An Introduction : AHM-250

The following statements describe common types of physician/hospital integrated models:
(A)
The Alpha Company, which is owned by a group of investors, is a for-profit legal entity that buys entire physician practices, not just the tangible assets of the p

• A. Physician hospital organization medical foundation
• B. Medical foundation management services company
• C. Physician hospital organization physician practice management company
• D. Physician practice management company physician hospital organization

The main purpose of the Health Plan Employer Data and Information Set (HEDIS) is to provide

• A. measurements of plan performance and effectiveness that potential healthcare purchasers can use to compare quality offered by different healthcare plans
• B. expert consultation to end-users for solving specialized and complex healthcare problems through the use of a knowledge-based computer system
• C. a mathematical model that can predict future claim payments and premiums
• D. a comprehensive accreditation for PPOs

Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.

• A. The Optimum Health Group evaluates the medical necessity and appropriateness of proposed services and intervenes, if necessary, to redirect care to a more appropriate care setting.
• B. The Axis Medical Group examines provider practice patterns to identify areas in which services are being underused, overused, or misused and designs strategies to prevent inappropriate utilization in the future.
• C. UR nurses employed by the Friendship Health Plan monitor length of stay to identify factors that might contribute to unnecessary hospital days.
• D. The Serenity Healthcare Organization requires a plan member or the provider in charge of the member's care to obtain authorization for inpatient care before the member is admitted to the hospital.

In the paragraph below, a sentence contains two pairs of words enclosed in parentheses. Determine which word in each pair correctly completes the sentence. Then select the answer choice containing the two words that you have chosen. Many pharmacy benefit

• A. Therapeutic / never
• B. Generic / never
• C. Therapeutic / always
• D. Generic / always

The statements below describe technology used by two health plans to respond to incoming telephone calls:
- The Manor Health Plan uses an automated system that answers telephone calls with recorded or synthesized speech and prompts the caller to respond t

• A. Both Manor's system and Squire's device are applications of computer/telephone integration (CTI).
• B. Squire's device is best described as an interactive voice response (IVR) system.
• C. All of these statements are correct.
• D. Manor's system is best described as an automated call distributor (ACD).