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NEW QUESTION 1
A health plan’s choice of structure measures, process measures, and outcome measures to evaluate performance depends in part on the scientific soundness of the measures. One approach that a health plan can use to enhance scientific soundness is stratification, which refers to the
- A. identification and removal of unusual cases, such as patients with contraindications to a particular treatment, from consideration
- B. statistical adjustment of outcome measures to account for differences in the severity of illness or the presence of other medical conditions
- C. specification of a target population for a procedure and the data collection and analysis methods to be used
- D. elimination of variation within a patient population by dividing the population into groups that are at a similar level of risk
Answer: D
NEW QUESTION 2
The delivery of quality, cost-effective healthcare is a primary goal of both group healthcare and workers’ compensation programs. One difference between group healthcare and workers’ compensation is that workers’ compensation
- A. provides health and disability benefits to employees injured on the job only if the employer is at fault for the injury
- B. provides coverage for a variety of direct and indirect healthcare, disability, and workplace costs
- C. manages costs by including employee cost-sharing features in its benefit design
- D. places limits on benefits by restricting the amount of benefit payments or the number of covered hospital days or provider office visits
Answer: B
NEW QUESTION 3
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 4
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 5
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 6
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say
- A. that the construction of a data warehouse is quick and simple
- B. that a data warehouse addresses the problems associated with multiple data management systems
- C. that a data warehouse stores only current data
- D. all of the above
Answer: B
NEW QUESTION 7
Among this agency’s accreditation programs are accreditation for preferred provider organizations (PPOs), health plan call centers, and case management organizations. This agency classifies its standards as either “shall” standards or “should” standards.
- 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: A
NEW QUESTION 8
Determine whether the following statement is true or false:
The delegation of medical management functions to providers can occur without the transfer of financial risk.
- A. True
- B. False
Answer: A
NEW QUESTION 9
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 10
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 11
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
In most commercial health plans, the case management process is directed by a case manager whose responsibilities typically include
- A. focusing on a disabled member’s vocational rehabilitation and training
- B. approving all care decisions for patients under case management
- C. reducing the fragmentation of care that often results when individuals obtain services from several different providers
- D. all of the above
Answer: C
NEW QUESTION 12
This agency has authority over Programs of All-inclusive Care for the Elderly (PACE) and the State Children’s Health Insurance Program (SCHIP).
- A. Health Resources and Services Administration (HRSA)
- B. Office of Personnel Management (OPM)
- C. Department of Health and Human Services (HHS)
- D. Department of Justice (DOJ)
Answer: C
NEW QUESTION 13
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 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.
The following statement(s) can correctly be made about Harbrace’s use of extra- contractual coverage:
* 1. Harbrace’s medical policy most likely establishes the procedure that Harbrace used to evaluate the value of Upzil for treating Ms. Ray
* 2. One way for Harbrace to reduce the risk associated with extra-contractual coverage is by including an alternative care provision in its contracts with purchasers
- A. Both 1 and 2
- B. 1 only
- C. 2 only
- D. Neither 1 nor 2
Answer: C
NEW QUESTION 15
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 16
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