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NEW QUESTION 1
Acute care refers to healthcare services for medical problems that
- A. are expected to continue for a minimum of 30 days
- B. are typically treated in a provider’s office or outpatient facility
- C. require prompt, intensive treatment by healthcare providers
- D. require low utilization of resources
Answer: C
NEW QUESTION 2
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 3
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 two terms or phrases that you have selected.
The process for collecting and analyzing data differs for quality assessment (QA) and quality improvement (QI). For QA, data collection focuses on (objective / both objective and subjective) data, and data analysis identifies the (degree / cause) of variance.
- A. objective / degree
- B. objective / cause
- C. both objective and subjective / degree
- D. both objective and subjective / cause
Answer: A
NEW QUESTION 4
The paragraph below contains two pairs of terms enclosed in parentheses. Select the term in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms you have chosen.
A primary distinction between skilled care and subacute care relates to the extent and medical complexity of the patient’s needs. Generally, subacute care patients require (more
/ fewer) services from physicians and nurses and (more / less) extensive rehabilitation services than do skilled care patients.
- A. more / more
- B. more / less
- C. fewer / more
- D. fewer / less
Answer: A
NEW QUESTION 5
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 6
The Harbor Health Plan’s formulary policy encourages network pharmacists who are asked to fill a prescription for a costly, brand-name drug to dispense a different chemical entity within the same drug class in order to reduce costs. This type of drug substitution is referred to as
- A. generic substitution, and prescriber approval is not required
- B. generic substitution, and prescriber approval is always required
- C. therapeutic substitution, and prescriber approval is not required
- D. therapeutic substitution, and prescriber approval is always required
Answer: D
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
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 9
With respect to the activities of MCO medical directors, it is correct to say that medical directors typically perform all of the following activities EXCEPT
- A. maintaining clinical practices
- B. delivering performance feedback to providers
- C. participating in utilization management (UM) activities
- D. educating other MCO staff about new clinical developments or provider innovations that might impact clinical practice management
Answer: A
NEW QUESTION 10
Performance variance can be classified as either common cause variance or special cause variance. The following statement(s) can correctly be made about special cause variance:
* 1. Inadequate staffing levels, employee errors, and equipment malfunctions are examples of special cause variance
* 2. Special cause variance is typically more difficult to detect and correct than is common cause variance
- A. Both 1 and 2
- B. 1 only
- C. 2 only
- D. Neither 1 nor 2
Answer: B
NEW QUESTION 11
The following statements are about health plans’ development of medical policies. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
- A. Technology assessment is applicable only to medical policy development for new medical procedures, devices, drugs, and tests.
- B. Technology assessment provides the scientific rationale for the medical policy section that specifies when a medical service is appropriate and when it is not.
- C. The medical policy development process includes both a clinical and an operational review of a proposed medical policy.
- D. The decision to accept or reject a proposed medical policy often depends on how a new technology compares to currently used interventions.
Answer: A
NEW QUESTION 12
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 13
Examples of alternative healthcare practitioners are chiropractors, naturopaths, and acupuncturists. The only well-established credentialing standards for alternative healthcare practitioners are those available from NCQA. These NCQA credentialing standards apply to
- A. chiropractors
- B. naturopaths
- C. acupuncturists
- D. all of the above
Answer: A
NEW QUESTION 14
Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray’s condition, her physician has prescribed Upzil, a medication that has Food and Drug Administration (FDA) approval only for the treatment of depression. Upzil has not been tested for safety or effectiveness in the treatment of migraine headache. Although Harbrace’s medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray.
In this situation, the prescribing of Upzil for Ms. Ray’s headaches is an example of
- A. a cosmetic service
- B. an investigational service
- C. an off-label use
- D. a quality-of-life service
Answer: C
NEW QUESTION 15
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
Definitions of quality healthcare vary; however, four dimensions are essential to quality healthcare services. _____ is the quality dimension indicating that services result in the best care for a given cost or the lowest cost for a given level of care.
- A. Accessibility
- B. Effectiveness
- C. Acceptability
- D. Efficiency
Answer: D
NEW QUESTION 16
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