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NEW QUESTION 1
To see that utilization guidelines are consistently applied, UR programs rely on authorization systems. Determine whether the following statement about authorization systems is true or false:
Only physicians can make nonauthorization decisions based on medical necessity.

  • A. True
  • B. False

Answer: A

NEW QUESTION 2
The Garnet Health Plan uses provider profiling to measure and improve provider performance. Provider profiling most likely allows Garnet to

  • A. evaluate all providers without considering differences in risk
  • B. focus on specific clinical decisions of Garnet’s providers rather than on patterns of care
  • C. identify the outliers and high-value providers in its provider network
  • D. measure the effectiveness, but not the efficiency, of Garnet’s providers

Answer: C

NEW QUESTION 3
The paragraph below contains two pairs of terms enclosed in parentheses. Select the term in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Under a delegation arrangement, the (delegate / delegator) is responsible for performing the delegated function according to established standards, and the (delegate / delegator) is ultimately accountable for any deficiencies in the performance of the function.

  • A. delegate / delegate
  • B. delegate / delegator
  • C. delegator / delegate
  • D. delegator / delegator

Answer: B

NEW QUESTION 4
Acute care refers to healthcare services for medical problems that

  • A. are expected to continue for a minimum of 30 days
  • B. are typically treated in a provider’s office or outpatient facility
  • C. require prompt, intensive treatment by healthcare providers
  • D. require low utilization of resources

Answer: C

NEW QUESTION 5
Comparing the quality of managed Medicare programs with the quality of FFS Medicare programs is often difficult. Unlike FFS Medicare, managed Medicare programs

  • A. can measure and report quality only at the provider level
  • B. use a single system to deliver services to all plan members
  • C. provide an organizational focus for accountability
  • D. can use the same performance measures for all products and plans

Answer: C

NEW QUESTION 6
The following statements are about health plans’ development of medical policies. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

  • A. Technology assessment is applicable only to medical policy development for new medical procedures, devices, drugs, and tests.
  • B. Technology assessment provides the scientific rationale for the medical policy section that specifies when a medical service is appropriate and when it is not.
  • C. The medical policy development process includes both a clinical and an operational review of a proposed medical policy.
  • D. The decision to accept or reject a proposed medical policy often depends on how a new technology compares to currently used interventions.

Answer: A

NEW QUESTION 7
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 8
In order to be effective, a clinical pathway must improve quality and decrease costs.

  • A. True
  • B. False

Answer: B

NEW QUESTION 9
Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.
If Ms. Stanley agrees to the generic substitution, she will receive a drug that

  • A. has not been tested for safety and efficacy in large clinical trials
  • B. is available without a prescription at a reasonable cost
  • C. has been classified by the Food and Drug Administration (FDA) as safe, but that has not been proven fully effective
  • D. contains active ingredients that are identical to those of the prescribed brand-name drug

Answer: D

NEW QUESTION 10
Medicare beneficiaries can obtain healthcare benefits through fee-for-service (FFS) Medicare programs, Medicare medical savings account (MSA) plans, Medigap insurance, or coordinated care plans (CCPs). Unlike other coverage options, CCPs

  • A. provide only those benefits covered by Medicare Part A and Part B
  • B. are not subject to federal or state regulation
  • C. place primary care at the center of the delivery system
  • D. are structured as indemnity plans

Answer: C

NEW QUESTION 11
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.

  • A. A primary goal of UR is to address practice variations through the application of uniform standards and guidelines.
  • B. UR evaluates whether the services recommended by a member’s provider are covered under the benefit plan.
  • C. UR recommends the procedures that providers should perform for plan members.
  • D. A health plan’s UR program is usually subject to review and approval by the state insurance and/or health departments.

Answer: C

NEW QUESTION 12
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 13
In most health plans, the formulary system is developed and managed by a P&T committee. The P&T committee is responsible for

  • A. evaluating and selecting drugs for inclusion in the formulary
  • B. overseeing the manufacture, distribution, and marketing of prescription drugs
  • C. certifying the medical necessity of expensive, potentially toxic, or nonformulary drugs
  • D. all of the above

Answer: A

NEW QUESTION 14
This agency oversees fraud and abuse matters as they relate to medical management.

  • A. Health Resources and Services Administration (HRSA)
  • B. Office of Personnel Management (OPM)
  • C. Department of Health and Human Services (HHS)
  • D. Department of Justice (DOJ)

Answer: D

NEW QUESTION 15
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 16
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

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

Answer: A

NEW QUESTION 17
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

  • A. determine which healthcare services are medically necessary and appropriate for a particular patient in a particular situation
  • B. outline the services that will be delivered, the providers responsible for delivering the services, the timing of delivery, the setting in which services are delivered, and the expected outcomes of the interventions
  • C. cover only services delivered in an acute inpatient setting
  • D. address medical conditions that affect a small segment of a given population and with which the majority of providers are unfamiliar

Answer: B

NEW QUESTION 18
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