AHM-540 Medical Management Questions and Answers

The Noble Health Plan conducted a cost/benefit analysis of the following four prescription drugs:

Benefit Cost

Drug A $525 $350

Drug B $450 $250

Drug C $400 $200

Drug D $350 $100

According to this analysis, the drug that represents the most efficient use of resources is

In order for a health plan’s performance-based quality improvement programs to be effective, the desired outcomes must be

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

The following statement(s) can correctly be made about the scope of case management:

1. Case management incorporates activities that may fall outside a health plan’s typical responsibilities, such as assessing a member’s financial situation

2. Case management generally requires a less comprehensive and complex approach to a course of care than does utilization review

3. Case management is currently applicable only to medical conditions that require inpatient hospital care and are categorized as catastrophic in terms of health and/or costs

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.

The following statements are about QAPI as it applies to Medicare+Choice plans and Medicaid health plan entities. Select the answer choice containing the correct statement.

The following statements are about the characteristics of a utilization review (UR) program. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

Economically, health plans cannot provide coverage for every drug available from every manufacturer. As a result, purchaser contracts often include provisions specifying that certain drugs or drug types will not be covered. These provisions are referred to as

To facilitate electronic commerce (eCommerce), a health plan may establish a secured extranet. One true statement about a secured extranet is that it is

The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

The Balanced Budget Act (BBA) of 1997 established the use of ___________ to determine coverage of emergency services for Medicare and Medicaid enrollees in health plans.

The paragraph below contains two pairs of phrases enclosed in parentheses. Select the phrase in each pair that correctly completes the paragraph. The select the answer choice containing the two phrases you have selected.

Calvin Montrose, age 75, has difficulty performing basic self-care activities, such as bathing, dressing, and eating, without assistance. This information indicates that Mr. Montrose needs assistance with (activities of daily living / instrumental activities of daily living) that are used to measure his (functional status / health status).

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.

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

The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through

1. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

2. The National Committee for Quality Assurance (NCQA)

3. The American Accreditation HealthCare Commission/URAC (URAC)

Nilay Sharma suffered a small wound while working in his yard and was taken to a local hospital for treatment. A triage nurse at the hospital evaluated Mr. Sharma’s condition and directed him to an outpatient unit in the hospital where a physician assistant examined, cleaned, and sutured the wound. Mr. Sharma returned home following treatment. The care Mr. Sharma received at the hospital is an example of the type of care known as

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

Selene Varga is participating in her health plan’s disease management program for congestive heart failure. Ms. Varga’s health status is regularly monitored and managed by a licensed nurse who visits Ms. Varga at her home to administer treatment and assess the need for changes in Ms. Varga’s overall care plan. This information indicates that Ms. Varga is participating in the type of disease management program known as a

Three general categories of coverage policy—medical policy, benefits administration policy, and administrative policy—are used in conjunction with purchaser contracts to determine a health plan’s coverage of healthcare services and supplies. With respect to the characteristics of the three types of coverage policy, it is correct to say that a health plan’s

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

Many health plans use clinical pathways to help manage the delivery of acute care services to plan members. One true statement about clinical pathways is that they

Health plans conduct evaluations on the efficiency and effectiveness of their quality improvement activities. With regard to the effectiveness of quality improvement plans, it is correct to say that

Health plans arrange for the delivery of various levels of healthcare, including

1. Emergency care

2. Urgent care

3. Primary care delivered in a provider’s office

In a ranking of these levels of care according to cost, beginning with the least expensive level of care and ending with the most expensive level of care, the correct order would be

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

Various government and independent agencies have created tools to measure and report the quality of healthcare. One performance measurement tool that was developed by the Agency for Healthcare Research and Quality (AHRQ) is

Maxwell Midler’s health plan operates a drug formulary that includes a typical three-tier copayment structure with required copayments of $5, $10, and $25. Mr. Midler recently filled a prescription for a $75 drug that was not included in the formulary. According to the plan’s formulary copayment structure, the amount that Mr. Midler was required to pay for his prescription was

Increased demands for performance information have resulted in the development of various health plan report cards. With respect to most of the report cards currently available, it is correct to say

The Harbor Health Plan’s formulary policy encourages network pharmacists who are asked to fill a prescription for a costly, brand-name drug to dispense a different chemical entity within the same drug class in order to reduce costs. This type of drug substitution is referred to as

The following statement(s) can correctly be made about the characteristics of peer review:

1. Peer review is applicable to either single episodes of care or to entire programs of care

2. Most peer review is conducted concurrently

3. Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services furnished to Medicare and Medicaid recipients enrolled in health plans

The Garnet Health Plan uses provider profiling to measure and improve provider performance. Provider profiling most likely allows Garnet to

The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

Definitions of quality healthcare vary; however, four dimensions are essential to quality healthcare services. ________________ is the quality dimension indicating that services result in the best care for a given cost or the lowest cost for a given level of care.

Many health plans use HRA to target their preventive care programs to the healthcare needs of their members. With regard to HRA, it is correct to say that

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

Determine whether the following statement is true or false:

Participation in disease management programs is currently voluntary.

The following statements are about the use of hospitalists to manage inpatient care. Select the answer choice containing the correct statement.

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

One way that health plans can make their benefits more appealing to employers and employees is to offer coverage for specialty services. It is correct to say that specialty services typically

Private employers are key purchasers of health plan services. The following statement(s) can correctly be made about employer expectations about the quality and cost-effectiveness of healthcare services:

1. For both health maintenance organizations (HMOs) and non-HMO plans, employers typically have access to accreditation results and performance measurement reports to help them evaluate the quality of healthcare and service

2. Because of employers’ concern about the quality and costs of healthcare services available through health plans, direct contracting has become a dominant model among employers who sponsor health benefit programs for their employees

Outcomes management is a tool that health plans use to maximize all the results associated with healthcare processes. The following statement(s) can correctly be made about outcomes management:

1. The goal of outcomes management is to identify and implement treatments that are cost-effective and deliver the greatest value

2. Outcomes management introduces performance as a critical factor in the assessment and improvement of outcomes

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

One difference between outcomes research and clinical research is that outcomes research

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

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

The following statement(s) can correctly be made about medical management considerations for the Federal Employee Health Benefits Program (FEHBP):

1. FEHBP plan members who have exhausted the health plan’s usual appeals process for a disputed decision can request an independent review by the Office of Personnel Management (OPM)

2. All health plans that cover federal employees are required to develop and implement patient safety initiatives

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

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