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NEW QUESTION 1
Determine whether the following statement is true or false:
With respect to the size of a managed care organization (MCO) and its medical management operations, it is correct to say that large health plans typically have more integration among activities and less specialization of roles than do small MCOs.
- A. True
- B. False
Answer: B
NEW QUESTION 2
Determine whether the following statement is true or false:
Independent review organizations (IROs) can mediate disputes and offer advisory opinions to health plans on UR issues, but they cannot render binding decisions on appeals.
- A. True
- B. False
Answer: B
NEW QUESTION 3
The following statement(s) can correctly be made about performance measurement systems:
* 1.The most difficult purpose for a performance measurement system to address is to measure changes in outcomes caused by modifications in administrative or clinical treatment processes
* 2.A health plan needs different performance measurement systems to evaluate its administrative services and the clinical performance of its providers
- A. Both 1 and 2
- B. 1 only
- C. 2 only
- D. Neither 1 nor 2
Answer: C
NEW QUESTION 4
Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the
- A. lack of qualified providers in provider networks
- B. lack of resources necessary to establish case management programs for patients with complex conditions
- C. unstable eligibility status of Medicaid recipients
- D. inability of Medicaid recipients to change health plans or PCPs
Answer: C
NEW QUESTION 5
The following statements are about risk management for case management. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
- A. The use of a signed consent authorization form is consistent with accrediting agency standards for patient privacy and confidentiality of medical information.
- B. Case management that is initiated after a member has incurred substantial medical expenses is more likely to be viewed as a tool to cut costs rather than to improve outcomes.
- C. Health plan documents indicating that any case management delegates are separate, independent entities may reduce an health plan's exposure to risk.
- D. A case management file cannot be used to support the health plan's position in the event of a lawsuit.
Answer: D
NEW QUESTION 6
Accreditation is intended to help purchasers and consumers make decisions about healthcare coverage.
The following statements are about accreditation. Select the answer choice containing the correct statement.
- A. At the request of health plans, accrediting agencies gather the data needed for accreditation.
- B. Most purchasers and consumers review accreditation results when making decisions to purchase or enroll in a specific health plan.
- C. Accreditation is typically conducted by independent, not-for-profit organizations.
- D. All health plans are required to participate in the accreditation process.
Answer: C
NEW QUESTION 7
Occasionally, employers combine workers’ compensation, group healthcare, and disability programs into an integrated product known as 24-hour coverage. One true statement about 24-hour coverage is that it typically
- A. increases administrative costs
- B. requires plans to maintain separate databases of patient care information
- C. exempts plans from complying with state workers’ compensation regulations
- D. allows plans to apply disability management and return-to-work techniques to nonoccupational conditions
Answer: D
NEW QUESTION 8
To see that utilization guidelines are consistently applied, UR programs rely on authorization systems. Determine whether the following statement about authorization systems is true or false:
Only physicians can make nonauthorization decisions based on medical necessity.
- A. True
- B. False
Answer: A
NEW QUESTION 9
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.
The Millway Health Plan received a 15% reduction in the price of a particular pharmaceutical based on the volume of the drug Millway purchased from the manufacturer. This reduction in price is an example of a (rebate / price discount) and (is / is not) dependent on actual provider prescribing patterns.
- A. rebate / is
- B. rebate / is not
- C. price discount / is
- D. price discount / is not
Answer: D
NEW QUESTION 10
The Strathmore Health Plan uses clinical pathways to manage its acute care services. In order to reduce the risk of financial liability associated with the use of clinical pathways, Strathmore and its network hospitals should
- A. base pathways on relevant evidence reported in medical literature
- B. restrict each pathway to a single medical condition
- C. use pathways to establish a new standard of care
- D. allow providers to use only those interventions listed in the pathways
Answer: A
NEW QUESTION 11
Three general categories of coverage policy—medical policy, benefits administration policy, and administrative policy—are used in conjunction with purchaser contracts to determine a health plan’s coverage of healthcare services and supplies. With respect to the characteristics of the three types of coverage policy, it is correct to say that a health plan’s
- A. medical policy evaluates clinical services against specific benefits language rather than against scientific evidence
- B. benefits administration policy determines whether a particular service is experimental or investigational
- C. benefits administration policy focuses on both clinical and nonclinical coverage issues
- D. administrative policy contains the guidelines to be followed when handling member and provider complaints and disputes
Answer: D
NEW QUESTION 12
The nature of behavioral healthcare creates unique medical management challenges for health plans. One method health plans have used to support the delivery of appropriate services in a cost-effective manner is to
- A. remove behavioral healthcare services from the primary care setting
- B. shift behavioral healthcare from acute inpatient settings to alternative settings when feasible
- C. reserve the use of psychotherapy for treatment of those conditions that persist over long periods of time or for the life of the patient
- D. offer the same level of compensation to all of the professional disciplines that provide behavioral healthcare services to plan members
Answer: B
NEW QUESTION 13
The following statements are about health plans' complaint resolution procedures (CRPs). Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
- A. An health plan's CRPs reduce the likelihood of errors in decision making.
- B. CRPs typically provide for at least two levels of appeal for formal appeals.
- C. CRPs include only formal appeals and do not apply to informal complaints.
- D. Most complaints are resolved without proceeding through the entire CRP process.
Answer: C
NEW QUESTION 14
The following statement(s) can correctly be made about the hospitalist approach to inpatient care management:
* 1. Management of inpatient care by hospitalists may significantly reduce the length of stay and the total costs of care for a hospital admission
* 2. Most health plans that use hospitalists do so through a voluntary hospitalist program
* 3.A hospitalist’s familiarity with utilization management (UM) and quality management (QM) standards for inpatient care may reduce unnecessary variations in care and improve clinical outcomes
- A. All of the above
- B. 1 and 2 only
- C. 1 and 3 only
- D. 2 only
Answer: A
NEW QUESTION 15
The following statements are about the use of hospitalists to manage inpatient care. Select the answer choice containing the correct statement.
- A. A patient who has been transferred to a hospitalist for management of inpatient care usually continues to receive care from the hospitalist after discharge.
- B. Hospitalists are used primarily to manage care for obstetric, pediatric, and oncology patients.
- C. In order to serve as a hospitalist, a physician must have a background in critical care medicine.
- D. Hospitalists typically spend at least one-quarter of their time in a hospital setting.
Answer: D
NEW QUESTION 16
The following statement(s) can correctly be made about accrediting agency standards for delegation:
* 1. The National Committee for Quality Assurance (NCQA) allows health plans to delegate
all medical management functions, including the responsibility to perform delegation oversight activities
* 2. In some cases, accreditation standards for delegation oversight are reduced if the delegate has already been certified or accredited by the delegator’s accrediting agency
- A. Both 1 and 2
- B. 1 only
- C. 2 only
- D. Neither 1 nor 2
Answer: C
NEW QUESTION 17
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