Medical Management v4.0 (AHM-540) Flashcards
PBMs are accredited by the same organizations that accredit health plans.
A. True
B. False
B. False
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
A. High-risk processes
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
A. maintaining clinical practices
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 non-coverage of benefits based on medical necessity decisions to the cost of non-covered 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
A. Provision 1- ERISA Provision 2- HIPAA
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
B. that a data warehouse addresses the problems associated with multiple data management systems
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:
- Inadequate staffing levels, employee errors, and equipment malfunctions are examples of special cause variance
- 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
B. 1 only
The Quality Assessment Performance Improvement (QAPI) is a quality initiative designed to strengthen health plans efforts to protect and improve the health and satisfaction of Medicare and Medicaid health plan enrollees. The Centers for Medicare and Medicaid
Services (CMS) requires compliance with QAPI from
A. both Medicare+Choice plans and Medicaid health plans
B. Medicare+Choice plans only
C. Medicaid health plans only
D. neither Medicare+Choice plans nor Medicaid health plans
B. Medicare+Choice plans only
A health plan’s preventive care initiatives may be classified into three main categories: primary prevention, secondary prevention, and tertiary prevention. Secondary prevention refers to activities designed to
A. develop an appropriate treatment strategy for patients whose conditions require extensive, complex healthcare
B. educate and motivate members to prevent illness through their lifestyle choices
C. prevent the occurrence of illness or injury
D. detect a medical condition in its early stages and prevent or at least delay disease progression and complications
D. detect a medical condition in its early stages and prevent or at least delay disease progression and complications
Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Rays 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 Harbraces 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 Harbraces use of extra- contractual coverage:
- Harbraces medical policy most likely establishes the procedure that Harbrace used to evaluate the value of Upzil for treating Ms. Ray
- 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
C. 2 only
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
B. False
To facilitate electronic commerce (eCommerce), a health plan may establish a secured extranet. One true statement about a secured extranet is that it is
A. based on Web-based technologies
B. available only to the employees of the health plan
C. publicly available, so the potential exists for unauthorized access to a health plans proprietary systems
D. used to handle the majority of health plan eCommerce
A. based on Web-based technologies
The Brighton Health Plan regularly performs prospective UR for surgical procedures. Brightons prospective UR activities are likely to include
A. documenting the clinical details of the patient’s condition and care
B. tracking the length of inpatient stay
C. completing the discharge planning process
D. determining the most appropriate setting for the proposed course of care
D. determining the most appropriate setting for the proposed course of care
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
- Managing the costs of prescription drugs
- Promoting efficient and safe drug use
- Determining the health plans internal management responsibilities for pharmacy services
A. All of the above
B. 1 and 2 only
C. 2 and 3 only
D. 1 only
B. 1 and 2 only
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.
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.
In order for a health plans 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
A. achievable within a specified timeframe
