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NEW QUESTION 1
Elaine Newman suffered an acute asthma attack and was taken to a hospital emergency department for treatment. Because Ms. Newman’s condition had not improved enough following treatment to warrant immediate release, she was transferred to an observation care unit. Transferring Ms. Newman to the observation care unit most likely
- A. resulted in unnecessarily expensive charges for treatment
- B. prevented M
- C. Newman from receiving immediate attention for her condition
- D. gave M
- E. Newman access to more effective and efficient treatment than she could have obtained from other providers in the same region
- F. allowed clinical staff an opportunity to determine whether M
- G. Newman required hospitalization without actually admitting her
Answer: D
NEW QUESTION 2
In order to be effective, a clinical pathway must improve quality and decrease costs.
- A. True
- B. False
Answer: B
NEW QUESTION 3
Benchmarking is a quality improvement strategy used by some health plans. With regard to benchmarking, it is correct to say that
- A. cost-based benchmarking reveals why some areas of a health plan perform better or worse than comparable areas of other organizations
- B. diagnosis-related groups (DRGs) are a source of benchmarking data that describe individual procedures and cover both inpatient and outpatient care
- C. patient billing records provide a much more accurate account of procedure costs for benchmarking than do current procedural terminology (CPT) codes
- D. the focus of benchmarking for health plan has shifted from identifying the lowest cost practices to identifying best practices
Answer: D
NEW QUESTION 4
By definition, the development and implementation of parameters for the delivery of healthcare services to a health plan’s members is known as
- A. utilization management (UM)
- B. quality management (QM)
- C. care management
- D. clinical practice management
Answer: D
NEW QUESTION 5
The Brighton Health Plan regularly performs prospective UR for surgical procedures. Brighton’s prospective UR activities are likely to include
- A. documenting the clinical details of the patient’s condition and care
- B. tracking the length of inpatient stay
- C. completing the discharge planning process
- D. determining the most appropriate setting for the proposed course of care
Answer: D
NEW QUESTION 6
Michelle Durden, who is enrolled in a dental health maintenance organizations (DHMO) offered by her employer, is due for a routine dental examination. If the plan is typical of most DHMOs, then Ms. Durden
- A. must pay the entire cost of the examination
- B. must obtain a referral to a dentist from her primary care provider (PCP)
- C. can schedule the examination without preauthorization of payment by the DHMO
- D. can schedule an unlimited number of examinations and cleanings per year
Answer: C
NEW QUESTION 7
In order to achieve changes in outcomes, health plans make changes to existing structures and processes. The introduction of preauthorization as an attempt to control overuse of services is an example of a reactive change. Reactive changes are typically
- A. both planned and controlled
- B. planned, but they are rarely controlled
- C. controlled, but they are rarely planned
- D. neither planned nor controlled
Answer: C
NEW QUESTION 8
Health plans that choose to contract with external organizations for pharmacy services typically contract with pharmacy benefit managers (PBMs). Functions that a PBM typically performs for a health plan include
* 1.Managing the costs of prescription drugs
* 2.Promoting efficient and safe drug use
* 3.Determining the health plan’s internal management responsibilities for pharmacy services
- A. All of the above
- B. 1 and 2 only
- C. 2 and 3 only
- D. 1 only
Answer: B
NEW QUESTION 9
To measure performance for quality management, health plans collect and analyze three types of data: financial data, clinical data, and customer satisfaction data. The following statement(s) can correctly be made about the sources of clinical data:
* 1.Patient surveys are the most widely used source of disease-specific clinical information
* 2.Outcomes research studies sponsored by academic institutions and professional organizations have limited usefulness for particular health plans or individual providers
* 3.The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys address both physical and mental health status
- A. All of the above
- B. 1 and 2 only
- C. 2 and 3 only
- D. 3 only
Answer: C
NEW QUESTION 10
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
The QAPI (Quality Assessment Performance Improvement Program) is a Centers for Medicaid and Medicare Services (CMS) initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standards apply to
- A. standard medical-surgical services
- B. mental health and substance abuse services
- C. services offered to Medicare enrollees as optional supplementary benefits
- D. all of the above
Answer: D
NEW QUESTION 11
In most health plans, the formulary system is developed and managed by a P&T committee. The P&T committee is responsible for
- A. evaluating and selecting drugs for inclusion in the formulary
- B. overseeing the manufacture, distribution, and marketing of prescription drugs
- C. certifying the medical necessity of expensive, potentially toxic, or nonformulary drugs
- D. all of the above
Answer: A
NEW QUESTION 12
Many health plans use clinical pathways to help manage the delivery of acute care services to plan members. One true statement about clinical pathways is that they
- A. determine which healthcare services are medically necessary and appropriate for a particular patient in a particular situation
- B. outline the services that will be delivered, the providers responsible for delivering the services, the timing of delivery, the setting in which services are delivered, and the expected outcomes of the interventions
- C. cover only services delivered in an acute inpatient setting
- D. address medical conditions that affect a small segment of a given population and with which the majority of providers are unfamiliar
Answer: B
NEW QUESTION 13
Determine whether the following statement is true or false:
Under a carve-out arrangement for disease management, patients typically maintain their existing relationships with primary care providers (PCPs) for all care, including disease management.
- A. True
- B. False
Answer: B
NEW QUESTION 14
The following statement(s) can correctly be made about the scope of case management:
* 1. Case management incorporates activities that may fall outside a health plan’s typical responsibilities, such as assessing a member’s financial situation
* 2. Case management generally requires a less comprehensive and complex approach to a course of care than does utilization review
* 3. Case management is currently applicable only to medical conditions that require inpatient hospital care and are categorized as catastrophic in terms of health and/or costs
- A. All of the above
- B. 1 and 2 only
- C. 2 and 3 only
- D. 1 only
Answer: D
NEW QUESTION 15
Breanna Osborn is a case manager for a regional health plan. One component of Ms. Osborn’s job is the collection and evaluation of medical, financial, social, and psychosocial information about a member’s situation. This component of Ms. Osborn’s job is known as
- A. case identification
- B. case management planning
- C. healthcare coordination
- D. case assessment
Answer: D
NEW QUESTION 16
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.
Due to competitive pressures and consumer demand, many health plans now offer direct access or open access products. Under a direct access product, a member is (required / not required) to select a primary care provider (PCP), and is (required / not required) to obtain a referral from a PCP or the health plan before visiting a network specialist.
- A. required / required
- B. required / not required
- C. not required / required
- D. not required / not required
Answer: B
NEW QUESTION 17
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