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NEW QUESTION 1
When conducting performance assessment, a health pln may classify the key processes associated with its services into the following categories: high-risk, high-volume, problem- prone, and high-cost.
The following statements are about this classification of processes. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
- A. In some instances, relatively inexpensive processes can qualify as high-cost processes.
- B. Each process must be classified into a single category.
- C. High-risk processes most often involve medical interventions or treatment plans for acute illnesses or case management processes for complex conditions.
- D. Administrative processes such as scheduling appointments are examples of high- volume processes.
Answer: B
NEW QUESTION 2
In order for a health plan’s performance-based quality improvement programs to be effective, the desired outcomes must be
- A. achievable within a specified timeframe
- B. defined in terms of multiple results
- C. expressed in subjective, qualitative terms
- D. all of the above
Answer: A
NEW QUESTION 3
Readiness is an important consideration for the development of health promotion programs. Readiness refers to
- A. the availability of previously established health promotion programs to an health plan’s members through employers, providers, or community service agencies
- B. the appropriateness of a program’s educational approach, given the language, literacy level, and cultural sensitivities of the target population
- C. a member’s level of knowledge about existing health risks and problems and the member’s ability and willingness to adopt new health-related behaviors
- D. a member’s access to information technology, such as a video cassette recorder, a computer, or the Internet
Answer: C
NEW QUESTION 4
This agency’s accreditation decisions are based on the results of an on-site survey of clinical and administrative systems and processes, as well as the health plan’s performance on selected effectiveness of care and member satisfaction measures.
- A. American Accreditation HealthCare Commission/URAC (URAC)
- B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
- C. Community Health Accreditation Program (CHAP)
- D. National Committee for Quality Assurance (NCQA)
Answer: D
NEW QUESTION 5
Administrative action plans are used when performance problems or opportunities are related to the way the organization itself operates. The following statement(s) can correctly be made about administrative action plans:
* 1.Administrative action plans allow health plans to coordinate management activities
* 2.One function of administrative action plans is to integrate service across all levels of the organization
* 3.Administrative action plans are designed to improve outcomes by helping plan members assume responsibility for their own health
- A. All of the above
- B. 1 and 2 only
- C. 1 and 3 only
- D. 2 and 3 only
Answer: B
NEW QUESTION 6
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Ways that workers’ compensation health plans can help control the costs of job-related injuries and illnesses include
- A. applying strict definitions of medical necessity
- B. developing prevention and recovery programs
- C. applying out-of-network benefit reductions
- D. all of the above
Answer: B
NEW QUESTION 7
Vision care is typically separated into two categories: routine eye care and clinical eye care. The standard benefit plans offered by most health plans include coverage for
* 1. Routine eye care
* 2. Clinical eye care
- A. Both 1 and 2
- B. 1 only
- C. 2 only
- D. Neither 1 nor 2
Answer: C
NEW QUESTION 8
The following statements are about chronic and disabling conditions among children eligible for Medicaid. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
- A. Children with chronic conditions use more physician and nonphysician professional services than do children in the general population.
- B. The majority of chronic conditions affecting children in Medicaid programs are the same as those affecting children in the general population.
- C. Medicaid-eligible children are at risk for seriousmental and physical conditions.
- D. Children in Medicaid programs have a higher incidence of chronic disabling conditions than do children in the general population.
Answer: B
NEW QUESTION 9
A health plan's preventive care initiatives may be classified into three main categories: primary prevention, secondary prevention, and tertiary prevention. Secondary prevention refers to activities designed to
- A. develop an appropriate treatment strategy for patients whose conditions require extensive, complex healthcare
- B. educate and motivate members to prevent illness through their lifestyle choices
- C. prevent the occurrence of illness or injury
- D. detect a medical condition in its early stages and prevent or at least delay disease progression and complications
Answer: D
NEW QUESTION 10
Health plans communicate proposed performance changes through action statements. Select the answer choice containing an action statement that includes all of the required elements.
- A. The proportion of adult members who are screened for hypertension will increase by ten percent.
- B. Primary care providers (PCPs) will increase the proportion of children under the age of two who are up-to-date on immunizations by seven percent within one year.
- C. The QM program director will evaluate the level of provider compliance with clinicalpractice guidelines (CPGs).
- D. The disease management program director will increase participation by asthmatic children in the health plan’s pediatric asthma disease management program.
Answer: B
NEW QUESTION 11
One way that health plans evaluate their UR programs is by monitoring utilization rates. By definition, utilization rates typically
- A. indicate changes in the total amount of medical expenses or claim dollars paid for particular procedures
- B. measure the number of services provided per 1,000 members per year
- C. indicate standard approaches to care for many common, uncomplicated healthcare services
- D. report the number of times that a particular provider performs or recommends a service excluded from the benefit plan
Answer: B
NEW QUESTION 12
Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services
- A. must be offered as separate supplemental benefits or separate products
- B. lack clinical trials to evaluate their safety and effectiveness
- C. are not covered by state or federal consumer protection statutes
- D. focus on a specific illness, injury, or symptom rather than on the whole body
Answer: B
NEW QUESTION 13
The following statement(s) can correctly be made about medical management considerations for the Federal Employee Health Benefits Program (FEHBP):
* 1. FEHBP plan members who have exhausted the health plan’s usual appeals process for a disputed decision can request an independent review by the Office of Personnel Management (OPM)
* 2. All health plans that cover federal employees are required to develop and implement patient safety initiatives
- A. Both 1 and 2
- B. 1 only
- C. 2 only
- D. Neither 1 nor 2
Answer: A
NEW QUESTION 14
A health plan’s coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions:
* 1. In case of conflict between the purchaser contract and a health plan’s medical policy or benefits administration policy, the contract takes precedence
* 2. Purchaser contracts commonly exclude custodial care from their coverage of services and supplies
* 3. All of the criteria for coverage decisions must be included in the purchaser contract
- A. All of the above
- B. 1 and 2 only
- C. 2 only
- D. 3 only
Answer: B
NEW QUESTION 15
One true statement about state regulation of case management activities is that the majority of states
- A. have enacted laws that list specific quality management requirements for a case management program
- B. consider case management files to be medical records that must be retained for a specified length of time
- C. view case management similarly and follow similar patterns with their laws and regulations
- D. have enacted laws or regulations requiring licensure or certification of case managers
Answer: B
NEW QUESTION 16
Health plans conduct evaluations on the efficiency and effectiveness of their quality improvement activities. With regard to the effectiveness of quality improvement plans, it is correct to say that
- A. effectiveness is the relationship between what the organization puts into an improvement plan and what it gets out of the plan
- B. effectiveness is measured by reviewing outcomes to determine the accuracy or appropriateness of the strategy and the adequacy of resources allocated to that strategy
- C. the effectiveness of an action plan is typically measured with a concurrent evaluation
- D. an evaluation of plan effectiveness produces one of two results: the plan either (a) achieved the desired outcomes or (b) did not achieve the desired outcomes and is unlikely to do so under current conditions
Answer: B
NEW QUESTION 17
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