AHM-540 Medical Management Questions and Answers

The Riverside Health Plan is considering the following provider compensation options to use in its contracts with several provider groups and hospitals:

1. A discounted fee-for-service (DFFS) payment system

2. A case rate system

3. Capitation

If Riverside wants to use only those compensation methods that encourage the efficient use of resources, then the compensation method(s) that Riverside should consider for its new contracts include

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

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

Accreditation is intended to help purchasers and consumers make decisions about healthcare coverage.

The following statements are about accreditation. Select the answer choice containing the correct statement.

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

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.

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).

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.

Among this agency’s 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.

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.

Occasionally, employers combine workers’ compensation, group healthcare, and disability programs into an integrated product known as 24-hour coverage. One true statement about 24-hour coverage is that it 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

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.

Greenhouse’s prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).

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).

One way that health plans evaluate their UR programs is by monitoring utilization rates. By definition, utilization rates typically

The paragraph below contains an incomplete statement. Select the answer choice containing the 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 and relationships in the data.

The following statement(s) can correctly be made about the use of screening for secondary prevention:

1. Screening activities may involve specialty care providers as well as primary care providers (PCPs) and the health plan

2. Secondary prevention often results in more utilization of services immediately following screening

3. Screening focuses on members who have not experienced any symptoms of a particular illness

In order to provide a true measure of quality, the data collected by a quality indicator should accurately represent the service dimension being measured. This information indicates that the indicator should exhibit the characteristic known as

Benchmarking is a quality improvement strategy used by some health plans. With regard to benchmarking, it is correct to say that

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

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