PAHM study plan

Diagram the continuum of care settings (ambulatory, acute, post-acute, home, community) and label the payer mix typical of each

Distinguish among fee-for-service, managed care, and value-based delivery models by listing the incentives each creates for providers

Explain how accountable care organizations and patient-centered medical homes restructure care coordination

Identify the roles of primary care, specialty, and ancillary providers within a referral network

Map insurance product types (HMO, PPO, POS, EPO, HDHP) to their network, referral, and cost-sharing rules

Trace the member lifecycle from enrollment through claims to renewal, noting where utilization management intervenes

Define core managed care terms (premium, deductible, coinsurance, copay, out-of-pocket maximum) and compute a member's cost for a sample claim

Compare Medicare Advantage, Medicaid managed care, and commercial risk arrangements on benefit design

Contrast capitation, per diem, case rates, and DRG-based payment on how risk shifts between payer and provider

Calculate a provider's revenue under fee-for-service versus capitation for a hypothetical patient panel

Explain risk adjustment and why coding accuracy affects payment in risk-based contracts

Describe how stop-loss and reinsurance protect providers and plans in capitated arrangements

Break down a hospital claim into its DRG, APC, or CPT components and identify the coding inputs that drive payment

Explain the Medicare fee schedule, relative value units, and the geographic adjustment factors

Distinguish between the revenue cycle stages from scheduling through collections and name the key metric for each

Interpret a basic payer contract's rate terms and identify the clauses that shift financial risk

Apply a quality framework (structure, process, outcome) to classify at least six common quality measures

Interpret HEDIS-style and CMS Star Ratings measures and explain how they link to payment

Outline the core requirements of HIPAA privacy, security, and breach notification rules

Identify the compliance obligations created by Stark, Anti-Kickback, and False Claims Act exposure in provider arrangements

Describe accreditation and survey processes (e.g., Joint Commission, NCQA) and what each evaluates

Explain how EHR, HIE, and population health platforms support quality measurement and care gap closure

Distinguish data governance, data quality, and interoperability standards (HL7, FHIR) at a conceptual level

Describe how analytics (risk stratification, predictive modeling, dashboards) inform utilization and quality management

Apply de-identification and minimum necessary principles to a sample data-sharing scenario

Evaluate a strategic decision (e.g., entering a value-based contract) using SWOT and a basic break-even or margin analysis

Apply an ethical decision framework to a scenario involving resource allocation or conflict of interest

Explain how leadership structures and governance differ across payer, provider, and integrated delivery organizations

Assess how change management and stakeholder alignment affect implementation of a new care model

Synthesize the heaviest domains (1, 2, 3) into a single integrated review outline

Complete a timed practice assessment and categorize every miss by domain

Re-study the two lowest-scoring domains using targeted summaries

Draft a one-page exam-day strategy covering pacing, question triage, and common trap patterns