All About High Quality AHM-540 Test Question

NEW QUESTION 1
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 2
Determine whether the following statement is true or false:
Under a carve-out arrangement for disease management, patients typically maintain their existing relationships with primary care providers (PCPs) for all care, including disease management.

• A. True
• B. False

Answer: B

NEW QUESTION 3
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 4
Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located at a military installation. Ms. Wilson serves as a primary point of contact between enrollees and the TRICARE system and answers enrollees’ questions about plan options, eligibility, provider selection, and claims. This information indicates that Ms. Wilson serves as a

• A. lead agent
• B. beneficiary services representative
• C. health plan support contractor
• D. primary care manager (PCM)

Answer: B

NEW QUESTION 5
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 6
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 7
The Carlyle Health Plan uses the following clinical outcome measures to evaluate its diabetes and asthma disease management programs:
Measure 1: The percentage of diabetic patients who receive foot exams from their providers according to the program’s recommended guidelines Measure 2: The number of asthma patients who visited emergency departments for acute asthma attacks
From the answer choices below, select the response that correctly identifies whether these measures are true outcome measures or intermediate outcome measures. Measure 1- Measure 2-

• A. Measure 1-true outcome measure Measure 2-true outcome measure
• B. Measure 1-true outcome measure Measure 2-intermediate outcome measure
• C. Measure 1-intermediate outcome measure Measure 2-true outcome measure
• D. Measure 1-intermediate outcome measure Measure 2-intermediate outcome measure

Answer: C

NEW QUESTION 8
The following statement(s) can correctly be made about the use of screening for secondary prevention:
* 1. Screening activities may involve specialty care providers as well as primary care providers (PCPs) and the health plan
* 2. Secondary prevention often results in more utilization of services immediately following screening
* 3. Screening focuses on members who have not experienced any symptoms of a particular illness

• A. All of the above
• B. 1 and 3 only
• C. 2 and 3 only
• D. 1 only

Answer: A

NEW QUESTION 9
The Hall Health Plan gathered objective clinical information about the recommended uses and dosages of angiotensin-converting enzyme (ACE) inhibitors and presented the information to network providers to illustrate the appropriate use of these frequently prescribed and expensive drugs. This information indicates that Hall most likely educated its network providers through the use of

• A. detailing
• B. cognitive services
• C. counter detailing
• D. drug efficacy study implementation (DESI)

Answer: C

NEW QUESTION 10
Health plans often use accreditation as a means of evaluating the quality of care delivered to plan members. Accreditation of subacute care providers is available from the

• A. National Committee for Quality Assurance (NCQA)
• B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• C. American Accreditation HealthCare Commission/URAC (URAC)
• D. Foundation for Accountability (FACCT)

Answer: B

NEW QUESTION 11
Step-therapy is a form of prior authorization that reserves the use of more expensive medications for cases in which the use of less expensive medications has been unsuccessful. Step-therapy is appropriate for situations in which
* 1.A significant percentage of those treated with the initial therapy will require the second therapy
* 2.The delay created when a patient moves from one therapy to the next therapy will not cause serious or permanent effects

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: C

NEW QUESTION 12
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 13
The Fairview Health Plan uses a dual database approach to integrate information needed for its disease management program. This information indicates that Fairview uses an information management system that

• A. combines all existing information from all data sources into a single comprehensive system
• B. connects multiple databases with a central interface engine that acts as an information clearinghouse
• C. provides an outside vendor with pertinent data that the vendor compiles into an integrated database
• D. creates a separate database that pulls pertinent information from the health plan’s claims database, formats the information for easy analysis, and stores it in the separate database

Answer: D

NEW QUESTION 14
The following statements are about disease management programs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. The focus of disease management is on responding to the needs of individual members for extensive, customized healthcare supervision.
• B. Disease management programs serve to improve both clinical and financial outcomes for healthcare services related to chronic conditions.
• C. Tools such as preventive care, self-care, and decision support programs are used to support both case management and disease management.
• D. Disease management programs apply to both diseases and medical conditions that are not diseases, such as high-risk pregnancy, severe burns, and trauma.

Answer: A

NEW QUESTION 15
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 16
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.
One component of UR is an administrative review. An administrative review compares the proposed medical care to the applicable (medical policy / contract provision). This type of review (can / cannot) be conducted by a nonclinical staff member.

• A. medical policy / can
• B. medical policy / cannot
• C. contract provision / can
• D. contract provision / cannot

Answer: C

NEW QUESTION 17
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 18
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