Question 1

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

Accepted Answer

D

Question 2

The paragraph below contains an incomplete statement. Select the answer choice containingthe term that correctly completes the paragraph.Medical management programs often require the analysis of many types of data and information.__________________ is an automated process that analyzes variables to help detect patterns andrelationships in the data.

Accepted Answer

Data mining is the automated process that analyzes variables to help detect patterns and relationships in the data. Unbundling refers to the breaking down of a service or product into individual components, outsourcing refers to the practice of hiring another company to perform a task, and drilling down refers to a way of analyzing data by starting with a broad overview and then focusing on specific details. None of these options accurately describe the process of analyzing variables to detect patterns in data.

Question 3

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. Sharmas 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

Accepted Answer

The care Mr. Sharma received at the hospital is an example of the type of care known as urgent care. Urgent care is a type of medical care provided to patients who need immediate treatment for a medical condition or injury that is not severe enough to warrant a visit to the emergency room. Urgent care is provided on an outpatient basis, which means that patients can be treated and then return home on the same day.

Question 4

For this question, if answer choices (A) through (C) are all correct, select answer choice (D).Otherwise, select the one correct answer choice.The QAPI (Quality Assessment Performance Improvement Program) is a Centers for Medicaid andMedicare Services (CMS) initiative designed to strengthen health plans' efforts to protect andimprove the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standardsapply to

Accepted Answer

The QAPI quality assessment standards apply to all of the above, including standard medical-surgical services, mental health and substance abuse services, and services offered to Medicare enrollees as optional supplementary benefits.

Question 5

The following statements are about risk management for case management. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

Accepted Answer

This statement is false. A case management file can be used to support the health plan's position in the event of a lawsuit. The file is a record of the actions taken by case managers to support the patient's care and is admissible as evidence in court. The other statements are true - signed consent forms are necessary for patient privacy, case management can be viewed negatively if used to cut costs, and indicating that case management delegates are separate entities can reduce risk.

Question 6

Some health plans administer a questionnaire known as the Behavioral Risk Factor SurveillanceSystem (BRFSS) as part of their health risk assessment (HRA) processes. The following statements areabout the BRFSS. If statements (A) through (C) are all correct, select answer choice (D). Otherwise,select the one correct statement.

Accepted Answer

Statement A is incorrect as the BRFSS questionnaire was not specifically designed for use by health plans. Statement B is incorrect as health plans have some flexibility to customize the questionnaire. Statement C is correct as the BRFSS questionnaire is used to monitor behavioral risk factors associated with illness and injury among adults.

Question 7

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.

Accepted Answer

The delegation of medical management functions can occur without transferring financial risk, as these are separate aspects of healthcare management.

Question 8

The following statement(s) can correctly be made about accrediting agency standards for delegation: 1. The National Committee for Quality Assurance (NCQA) allows health plans to delegate all medical management functions, including the responsibility to perform delegation oversight activities 2. In some cases, accreditation standards for delegation oversight are reduced if the delegate has already been certified or accredited by the delegators accrediting agency

Accepted Answer

The NCQA does allow delegation of medical management functions but requires the health plan to maintain oversight responsibility. However, accreditation standards for delegation oversight can be reduced if the delegate is already certified or accredited by the same agency.

Question 9

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

Accepted Answer

Clinical pathways 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. They do not determine which services are medically necessary and appropriate for a particular patient in a particular situation but rather help manage the delivery of acute care services to plan members. Clinical pathways can cover services delivered in various settings, not just acute inpatient settings, and can address medical conditions that affect a large segment of a given population, not just a small segment.

Question 10

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

Accepted Answer

A generic drug is required by the FDA to contain the same active ingredients as the brand-name drug, and it must be proven to be equally safe and effective. While it may not have undergone large clinical trials, it is still subject to rigorous testing before it is approved. Additionally, generic drugs are typically available at a much lower cost than brand-name drugs, making them a more affordable option for patients.

Question 11

The Strathmore Health Plan uses clinical pathways to manage its acute care services. In order to reduce the risk of financial liability associated with the use of clinical pathways, Strathmore and its network hospitals should

Accepted Answer

By basing pathways on relevant evidence reported in medical literature, Strathmore can ensure that the pathways are backed by scientific research and have a higher likelihood of success in improving patient outcomes. This can also help to reduce the risk of financial liability associated with the use of clinical pathways, as the use of evidence-based pathways is generally viewed as best practice and is less likely to lead to litigation. Restricting each pathway to a single medical condition (Choice B) may be overly restrictive and limit the potential benefits of clinical pathways, while using pathways to establish a new standard of care (Choice C) is inherently risky and could lead to liability if the pathways are not successful or if they are not backed by scientific evidence. Allowing providers to use only those interventions listed in the pathways (Choice D) may also be overly restrictive and limit providers' ability to provide customized care to individual patients.

Question 12

The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Select the term or phrase in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms or phrases you have chosen. TRICARE enrollees have the right to challenge authorization and coverage decisions. Such challenges are referred to as (appeals / grievances) and are typically handled by the (TRICARE contractor / Area Field Office).

Accepted Answer

Appeals are the correct term for challenging authorization and coverage decisions, and these are typically handled by the TRICARE contractor.

Question 13

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. The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen. Greenhouses prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).

Accepted Answer

According to the paragraph, the pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary, indicating that the plan formulary is closed. Additionally, the paragraph states that compliance by patients and providers is mandatory to the plan formulary, indicating that the correct term is mandatory. Therefore, the correct answer is C) closed / mandatory.

Question 14

Among this agencys 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.

Accepted Answer

URAC is known for accrediting PPOs, health plan call centers, and case management organizations, and it uses "shall" and "should" standards.

Question 15

To measure performance for quality management, health plans collect and analyze three typesof data: financial data, clinical data, and customer satisfaction data. The following statement(s) cancorrectly be made about the sources of clinical data:1.Patient surveys are the most widely used source of disease-specific clinical information2.Outcomes research studies sponsored by academic institutions and professional organizations havelimited usefulness for particular health plans or individual providers3.The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys address both physical and mentalhealth status

Accepted Answer

Statement 1 is incorrect as patient surveys are just one type of clinical data and may not necessarily provide disease-specific information.

Statement 2 is true as outcomes research studies may not always be applicable to a particular health plan or provider.

Statement 3 is true as the SF-36 and HSQ-39 surveys are validated tools for evaluating both physical and mental health status.

Question 16

Since its inception, Medicare has undergone a number of changes because of legal andregulatory action. One result of the Balanced Budget Act (BBA) of 1997 has been to

Accepted Answer

The Balanced Budget Act of 1997 expanded Medicare benefits by mandating coverage for certain preventive services, such as mammograms and colorectal cancer screenings.

Question 17

Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services

Accepted Answer

Many types of CAM services lack clinical trials to evaluate their safety and effectiveness, which presents potential liability for health plans that offer them. This is because if a patient is harmed by a CAM service, the health plan could be held responsible for not adequately researching the safety and effectiveness of the service before offering it as a benefit.

Question 18

Most health plans require a PCP referral or precertification for CAM benefits.

Accepted Answer

The answer of Most health plans require a PCP referral...

Question 19

Selene Varga is participating in her health plans disease management program for congestive heart failure. Ms. Vargas 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. Vargas overall care plan. This information indicates that Ms. Varga is participating in the type of disease management program known as a

Accepted Answer

The description of Ms. Varga's disease management program indicates that it is a case management model program. This type of program involves a licensed nurse or other healthcare professional regularly monitoring and managing a patient's condition, often through home visits or telephone check-ins, and coordinating care among different providers as needed. This is in contrast to other models such as the coordinated outreach model, which emphasizes patient education and self-management, or the hub-and-spoke model, which focuses on using a central location to coordinate care for remote patients. The group clinic model, meanwhile, involves multiple patients receiving care and support together in a group setting.

Question 20

A health plans coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions: 1.In case of conflict between the purchaser contract and a health plans medical policy or benefits administration policy, the contract takes precedence 2.Purchaser contracts commonly exclude custodial care from their coverage of services and supplies 3.All of the criteria for coverage decisions must be included in the purchaser contract

Accepted Answer

1. This statement is correct as purchaser contracts take precedence over medical policies or benefits administration policies in case of any conflict.

2. This statement is also correct as custodial care is often excluded from coverage in purchaser contracts.

3. This statement is incorrect as purchaser contracts generally do not include all criteria for coverage decisions, but rather outline the terms of the agreement between the health plan and the purchaser.

Exam 1: AHM Medical Management