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NEW QUESTION 1
For this question, if answer choices (a) through (c) are all correct, select answer choice (d). Otherwise, select the one correct answer choice.
Well-crafted clinical practice guidelines (CPGs) can benefit healthcare delivery processes and outcomes by
- A. providing a framework for care while also allowing for patient-specific variations, based on physician judgment
- B. serving as a basis for evaluating whether providers are practicing in accordance with accepted standards
- C. focusing on the prevention or early detection of a particular condition
- D. all of the above
Answer: D
NEW QUESTION 2
For this question, if answer choices (1) through (3) are all correct, select answer choice (4). Otherwise, select the one correct answer choice.
Health plans sometimes delegate selected medical management activities to their providers or other external entities. Activities that are frequently delegated include
- A. utilization review (UR)
- B. quality management (QM)
- C. preventive health services
- D. all of the above
Answer: A
NEW QUESTION 3
The Westchester Health Plan classifies its key processes into the following categories: high-risk, high-volume, problem-prone, and high-cost. Westchester also prioritizes the categories in terms of importance. The process category that Westchester most likely ranks highest in importance is
- A. High-risk processes
- B. High-volume processes
- C. Problem-prone processes
- D. High-cost processes
Answer: A
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 case management team at the Hightower Health Plan reviewed the medical records of the following two plan members to determine the type of care each one needs and the most appropriate setting for that care:
Ira Morton was hospitalized for a severe stroke. Although his medical condition is stable, the stroke left him partially paralyzed and he will require extensive rehabilitation and 24- hour medical care.
Theresa Finley is recovering from a total hip replacement and is in need of short-term physical therapy and twice-weekly visits from a licensed nurse to check her blood pressure and the healing of her incision.
From the answer choices below, select the response that correctly identifies the level of care that would be most appropriate for Mr. Morton and Ms. Finley.
- A. M
- B. Morton-acute care M
- C. Finley-subacute care
- D. M
- E. Morton-palliative care M
- F. Finley-acute care
- G. M
- H. Morton-subacute care M
- I. Finley-skilled care
- J. M
- K. Morton-skilled care M
- L. Finley-palliative care
Answer: C
NEW QUESTION 6
Some health plans administer a questionnaire known as the Behavioral Risk Factor Surveillance System (BRFSS) as part of their health risk assessment (HRA) processes. The following statements are about the BRFSS. If statements (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct statement.
- A. This questionnaire was designed specifically for use by health plans.
- B. Each health plan must use the same form of the questionnaire, with no additions or modifications.
- C. This questionnaire monitors the prevalence of the major behavioral risks associated with illness and injury among adults.
- D. All of the above statements are correct.
Answer: C
NEW QUESTION 7
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 8
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 9
Federal laws, such as the Employee Retirement Income Security Act (ERISA), the Balanced Budget Act (BBA) of 1997, and the Health Insurance Portability and Accountability Act (HIPAA), have affected medical management activities by health plans. Consider the following provisions of federal regulations:
Provision 1—Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered treatment and does not allow health plan members to obtain compensatory or punitive damages
Provision 2—Establishes electronic data security standards, which define the security measures that healthcare organizations must take to protect the confidentiality of electronically stored and transmitted patient information From the answer choices below, select the response that correctly identifies the federal laws that include Provision 1 and Provision 2, respectively.
- A. Provision 1- ERISA Provision 2- HIPAA
- B. Provision 1- HIPAA Provision 2- ERISA
- C. Provision 1- BBA of 1997 Provision 2- HIPAA
- D. Provision 1- ERISA Provision 2- BBA of 1997
Answer: A
NEW QUESTION 10
Designing effective medical management programs for Medicare beneficiaries requires an understanding of the unique health needs of the Medicare population. One characteristic of Medicare beneficiaries is that they typically
- A. do not experience mental health problems
- B. consume more than half of all prescription drugs
- C. are likely to equate quality with the technical aspects of clinical procedures
- D. require longer and more costly recovery periods following acute illnesses or injuries than does the general population
Answer: D
NEW QUESTION 11
To improve members’ abilities to make appropriate care decisions about specific medical problems, some health plans use a form of decision support known as telephone triage programs. The following statements are about telephone triage programs. Select the answer choice containing the correct statement.
- A. The primary role of telephone triage clinical staff is to diagnose the caller’s condition and give medical advice.
- B. Quality management (QM) for telephone triage programs typically focuses on the clinical information provided rather than on the quality of service.
- C. Currently, none of the major accrediting agencies offers an accreditation program specifically for telephone triage programs.
- D. A telephone triage program may also include a self-care component.
Answer: B
NEW QUESTION 12
PBMs are accredited by the same organizations that accredit health plans.
- A. True
- B. False
Answer: B
NEW QUESTION 13
Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans typically use home healthcare include
* 1. The period prior to a hospital admission
* 2. The period following discharge from a hospital
- A. Both 1 and 2
- B. 1 only
- C. 2 only
- D. Neither 1 nor 2
Answer: A
NEW QUESTION 14
The American Accreditation HealthCare Commission/URAC (URAC) has an accreditation program specifically for case management services. From the answer choices below, select the response that correctly identifies the type(s) of case management services addressed by URAC’s standards and the type(s) of organizations to which these standards may be applied.
- A. Type(s) of Services-on-site services only Type(s) of Organization-health plans only
- B. Type(s) of Services-on-site services only Type(s) of Organization-any organization that performs case management functions
- C. Type(s) of Services-both telephonic and on-site services Type(s) of Organization-health plans only
- D. Type(s) of Services-both telephonic and on-site services Type(s) of Organization-any organization that performs case management functions
Answer: D
NEW QUESTION 15
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 16
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