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NEW QUESTION 1
In order to achieve changes in outcomes, health plans make changes to existing structures and processes. The introduction of preauthorization as an attempt to control overuse of services is an example of a reactive change. Reactive changes are typically
- A. both planned and controlled
- B. planned, but they are rarely controlled
- C. controlled, but they are rarely planned
- D. neither planned nor controlled
Answer: C
NEW QUESTION 2
The Mental Health Parity Act (MHPA) of 1996 is a federal law that establishes requirements for behavioral healthcare coverage for group plan members. The MHPA
- A. requires health plans to offer mental health benefits to all eligible members
- B. prohibits health plans that offer mental health benefits from imposing lower annual or lifetime dollar limits on mental illnesses than they do on physical illnesses
- C. provides an exemption for health plans that can demonstrate cost savings of more than 1 percent
- D. prohibits health plans from limiting the number of outpatient visits or inpatient dayscovered under the plan
Answer: B
NEW QUESTION 3
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 4
Comorbidity can have a significant impact on the effective implementation of disease management programs. Comorbidity can correctly be defined as the
- A. degree to which the progression of a disease or condition is understood
- B. prevalence or rate of a sickness or injury within a given population
- C. degree of severity of a particular disease or condition
- D. presence of a chronic condition or added complication other than the condition that requires medical treatment
Answer: D
NEW QUESTION 5
The following statement(s) can correctly be made about utilization guidelines:
* 1. When developing utilization guidelines, health plans balance evidence-based criteria with experience-based criteria
* 2. Utilization guidelines indicate when a UR nurse should refer a decision to a physician reviewer
- A. Both 1 and 2
- B. 1 only
- C. 2 only
- D. Neither 1 nor 2
Answer: A
NEW QUESTION 6
The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self- care most likely would not be appropriate.
- A. Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area.
- B. Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day.
- C. Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility.
- D. Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.
Answer: A
NEW QUESTION 7
Since its inception, Medicare has undergone a number of changes because of legal and regulatory action. One result of the Balanced Budget Act (BBA) of 1997 has been to
- A. expand Medicare benefits by mandating coverage for certain preventive services
- B. reduce the number of organizations that can deliver covered services
- C. encourage growth of managed Medicare programs in all markets
- D. increase the number of “zero premium” plans available to Medicare beneficiaries
Answer: A
NEW QUESTION 8
Most health plans require a PCP referral or precertification for CAM benefits.
- A. True
- B. False
Answer: B
NEW QUESTION 9
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 10
The following statements are about the use of provider profiling for pharmacy benefits. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
- A. Health plans typically use provider profiles to improve the quality of care associated with the use of prescription drugs.
- B. Provider profiles identify prescribing patterns that fall outside normal ranges.
- C. Health plans can motivate providers to change their prescribing patterns by sharing profile information with plan members and the general public.
- D. Provider profiles are effective in modifying individual prescribing patterns, but they have little effect on group prescribing patterns.
Answer: D
NEW QUESTION 11
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.
The Millway Health Plan received a 15% reduction in the price of a particular pharmaceutical based on the volume of the drug Millway purchased from the manufacturer. This reduction in price is an example of a (rebate / price discount) and (is / is not) dependent on actual provider prescribing patterns.
- A. rebate / is
- B. rebate / is not
- C. price discount / is
- D. price discount / is not
Answer: D
NEW QUESTION 12
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 13
The nature of behavioral healthcare creates unique medical management challenges for health plans. One method health plans have used to support the delivery of appropriate services in a cost-effective manner is to
- A. remove behavioral healthcare services from the primary care setting
- B. shift behavioral healthcare from acute inpatient settings to alternative settings when feasible
- C. reserve the use of psychotherapy for treatment of those conditions that persist over long periods of time or for the life of the patient
- D. offer the same level of compensation to all of the professional disciplines that provide behavioral healthcare services to plan members
Answer: B
NEW QUESTION 14
The Glenway Health Plan’s pharmacy and therapeutics (P&T) committee conducted pharmacoeconomic research to measure both the clinical outcomes and costs of two new cholesterol-reducing drugs. Results were presented as a ratio showing the cost required to produce a 1 mcg/l decrease in cholesterol levels. The type of pharmacoeconomic research that Glenway conducted in this situation was most likely
- A. cost-effectiveness analysis (CEA)
- B. cost-minimization analysis (CMA)
- C. cost-utility analysis (CUA)
- D. cost of illness analysis (COI)
Answer: A
NEW QUESTION 15
Determine whether the following statement is true or false:
All health plans participating in the Federal Employee Health Benefits Program (FEHBP) are required to use the Consumer Assessment of Health Plans (CAHPS) to measure customer satisfaction.
- A. True
- B. False
Answer: A
NEW QUESTION 16
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 17
PBMs are accredited by the same organizations that accredit health plans.
- A. True
- B. False
Answer: B
NEW QUESTION 18
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