ahm 540 - tests

Assignment 1: The Medical Management Function

Reading 1A: The Role of Medical Management in a health plan

Define the term medical management and explain the goals of this function Describe some common components of medical management programs Describe the role of the medical director in a health plan Explain the purpose of medical management committees and identify several common types of

medical management committees Define the terms delegation and subdelegation Explain why health plans sometimes delegate medical management activities

Instructions: 1. Select or enter the best answer for each of the 7 questions. 2. Answer all the questions. Remember to scroll down if

necessary.

3. Click Complete the Test to score your answers and view a report.

1. By definition, the development and implementation of parameters for the delivery of healthcare services to a health plan’s members is known as

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2. utilization management (UM) quality management (QM) care management clinical practice management

2. Determine whether the following statement is true or false: With respect to the size of a managed care organization (MCO) and its medical management operations, it is correct to say that large health plans typically have more integration among activities and less specialization of roles than do small MCOs.

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3.

True False

3. 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

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4. maintaining clinical practices delivering performance feedback to providers participating in utilization management (UM) activities educating other MCO staff about new clinical developments or provider innovations that might impact clinical practice management

4. 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

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5.

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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.

delegate / delegate delegate / delegator delegator / delegate delegator / delegator

5. 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.

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6. True False

6. For this question, if answer choices (1) through (3) are all correct, select answer choice (4). Otherwise, select the one correct answer choice. Health plans sometimes delegate selected medical management activities to their providers or other external entities. Activities that are frequently delegated include

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7.

utilization review (UR) quality management (QM) preventive health services all of the above

7. MCOs usually have a formal program for the oversight of delegated activities. The following statements concern typical delegation oversight programs. Select the answer choice containing the correct statement.

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A letter of intent is the contractual document that describes the delegated functions and the responsibilities of the MCO and the delegate. In most cases, the evaluation of a candidate for delegation is based entirely on the candidate’s application and supporting documentation and does not include an on-site assessment of the candidate. Under most delegation agreements, an MCO cannot terminate the agreement before the end date stated in the agreement. One objective for a delegation oversight program is to integrate any delegated activities into the MCO’s overall programs for medical management and other functions.

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1 D

2 B

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3 A

4 B

5 A

6 A

7 D

Reading 1B: The Relationship of Medical Management to Other Health Plan Functions

Explain the relationship between medical management and each of the following health plan departments:

Network management Risk management Legal affairs Claims administration Finance Sales and marketing Understand the role of information management in medical management operations and reporting Describe some of the technologies that health plans use to manage information

Instructions: 1. Select or enter the best answer for each of the 6 questions. 2. Answer all the questions. Remember to scroll down if necessary.

3. Click Complete the Test to score your answers and view a report. 1. 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 system2. A case rate system3. 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

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2.

1, 2, and 3 1 and 2 only 2 and 3 only 3 only

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

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3.

based on Web-based technologies available only to the employees of the health plan publicly available, so the potential exists for unauthorized access to a health plan’s proprietary systems used to handle the majority of health plan eCommerce

3. The following statements are about health plans’ use of electronic data interchange (EDI). Three of the statements are true and one is false. Select the answer choice containing the FALSE ALSE statement.

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4. One advantage of EDI over manual data management systems is improved data integrity.

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EDI may use the Internet as the communication link between the participating parties. EDI involves back-and-forth exchanges of information concerning individual transactions. The data format for EDI is agreed upon by the sending and receiving parties.

4. For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. 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

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5.

that the construction of a data warehouse is quick and simple that a data warehouse addresses the problems associated with multiple data management systems that a data warehouse stores only current data all of the above

5. 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.

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6.

Unbundling Outsourcing Data mining Drilling down

6. One method of transferring the information in electronic medical records (EMRs) is through a health information network (HIN). The following statements are about HINs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

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A HIN may afford a health plan better measurements of outcomes and provider performance. The use of a HIN typically increases a health plan’s exposure to liability for poor care. Most HINs are Internet-based rather than built on proprietary computer networks. Currently, the majority of health plans do not have HINs that are capable of transferring medical records among their network providers.

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1 C

2 A

3 C

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4 B

5 C

6 B

Reading 1C: Environmental Influences on Medical Management

Describe the types of environmental factors that affect medical management programs of health plans

Discuss the expectations of purchasers, providers, and plan members for medical management Describe the major federal and state regulatory requirements that affect medical management Describe how environmental factors influence a health plan's delegation of medical management

functions Identify the main accrediting agencies and explain the impact of accreditation on medical

management


3. Click Complete the Test to score your answers and view a report. 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

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2.

Both 1 and 2 1 only 2 only Neither 1 nor 2

2. State governments serve as both regulators and purchasers of health plan services. The influence of state governments as purchasers is focused on

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3. Medicare and TRICARE programs Medicaid and workers’ compensation programs Medicare and Medicaid programs TRICARE and workers’ compensation programs

3. 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

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4.

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management activities by health plans. Consider the following provisions of federal regulations:

Provision 1—Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered 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.

Provision 1- ERISA Provision 2- HIPAA Provision 1- HIPAA Provision 2- ERISA Provision 1- BBA of 1997 Provision 2- HIPAA Provision 1- ERISA Provision 2- BBA of 1997

4. 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

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5.

both Medicare+Choice plans and Medicaid health plans Medicare+Choice plans only Medicaid health plans only neither Medicare+Choice plans nor Medicaid health plans

5. This agency has authority over Programs of All-inclusive Care for the Elderly (PACE) and the State Children’s Health Insurance Program (SCHIP).

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6. Health Resources and Services Administration (HRSA) Office of Personnel Management (OPM) Department of Health and Human Services (HHS) Department of Justice (DOJ)

6. This agency oversees the Federal Employee Health Benefits Program (FEHBP).

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7. This agency oversees fraud and abuse matters as they relate to medical management.

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8. The Midwest Health Plan delegated utilization review (UR) activities to the Tri-City Utilization Review Organization. After Tri-City improperly recommended denial of payment for services to a Midwest plan member, the plan member filed suit. The court ruled that Midwest was responsible for Tri-City’s actions because of the relationship between Midwest and Tri-City. This situation is an illustration of a legal concept known as

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9.

vicarious liability fraud a tying arrangement subdelegation

9. 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.

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10.

At the request of health plans, accrediting agencies gather the data needed for accreditation. Most purchasers and consumers review accreditation results when making decisions to purchase or enroll in a specific health plan. Accreditation is typically conducted by independent, not-for-profit organizations. All health plans are required to participate in the accreditation process.

10. 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 delegator’s accrediting agency

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11.














11. 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

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the Health Plan Employer Data and Information Set (HEDIS®), which is a report card system for hospitals and long-term care facilities HEDIS, which is a performance measurement tool that addresses both effectiveness of care and plan member satisfaction the Consumer Assessment of Health Plans (CAHPS®), which was established to develop and implement a national strategy for quality measurement and reporting CAHPS, which is a tool that measures consumer satisfaction with specific aspects of health plan services

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1 D2 B3 A4 B5 C6 B7 D8 A9 C10 C11 D

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Assignment 2: Clinical Practice Management

Reading 2A: Clinical Practice Management

Describe the components of a health plan's coverage policy List several types of services that health plans typically limit or exclude Describe the types of coverage issues typically addressed by medical policy Explain the importance of technology assessment as it relates to medical policy Explain the role of clinical practice guidelines


3. Click Complete the Test to score your answers and view a report. 1. The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph. To manage the delivery of healthcare services to their members, health plans use clinical practice parameters. ___________________ is the type of clinical practice parameter that a health plan uses to make coverage decisions concerning medical necessity and appropriateness.

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2.

A clinical practice guideline (CPG) Medical policy Benefits administration policy A standard of care

2. 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

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3.

medical policy evaluates clinical services against specific benefits language rather than against scientific evidence benefits administration policy determines whether a particular service is experimental or investigational benefits administration policy focuses on both clinical and nonclinical coverage issues administrative policy contains the guidelines to be followed when handling member and provider complaints and disputes

3. A health plan’s 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 plan’s 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

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4.










purchaser contractAll of the above 1 and 2 only 2 only 3 only

4. Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray’s 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 Harbrace’s medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray. In this situation, the prescribing of Upzil for Ms. Ray’s headaches is an example of

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5.

a cosmetic service an investigational service an off-label use a quality-of-life service

5. Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray’s 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 Harbrace’s 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 Harbrace’s use of extra-contractual coverage:

1. Harbrace’s medical policy most likely establishes the procedure that Harbrace used to evaluate the value of Upzil for treating Ms. Ray

2. 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

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6.


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

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choice containing the FALSE statement. 7. Technology assessment is applicable only to medical policy development for new medical procedures, devices, drugs, and tests. Technology assessment provides the scientific rationale for the medical policy section that specifies when a medical service is appropriate and when it is not. The medical policy development process includes both a clinical and an operational review of a proposed medical policy. The decision to accept or reject a proposed medical policy often depends on how a new technology compares to currently used interventions.

7. 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

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providing a framework for care while also allowing for patient-specific variations, based on physician judgment serving as a basis for evaluating whether providers are practicing in accordance with accepted standards focusing on the prevention or early detection of a particular condition all of the above

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Assignment 3: Quality Management in health plan

Reading 3A: Quality Management

Describe the major steps in the quality management process Describe the role of outcomes in quality management Identify the characteristics, uses, and sources of quality standards Describe the differences between traditional healthcare and population-based healthcare Describe how quality management relates to risk management and information

management


3. Click Complete the Test to score your answers and view a report. 1. 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.

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2.

Accessibility Effectiveness Acceptability Efficiency

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

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3. provides an absolute measure of treatment results, whereas clinical research provides a relative measure of results focuses on treatment effectiveness, whereas clinical research focuses on treatment efficacy examines diseases and treatments in isolation, whereas clinical research considers the effects of changes in health status and quality of life gathers outcomes data from controlled clinical trials, whereas clinical research collects and analyzes clinical, financial, and administrative data

3. 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

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4.

Both 1 and 2










1 only 2 only Neither 1 nor 2

4. The paragraph below contains two pairs of terms 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. Health plans use both internal and external standards to assess the quality of the services that they provide. (Internal / External) standards are based on information such as published industry-wide averages or best practices of recognized industry leaders. Health plans primarily rely on (internal / external) standards to evaluate healthcare services.

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5.

Internal / internal Internal / external External / internal External / external

5. 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.

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6.

True False

6. This agency’s accreditation decisions are based on the results of an on-site survey of clinical and administrative systems and processes, as well as the health plan’s performance on selected effectiveness of care and member satisfaction measures.

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7.

American Accreditation HealthCare Commission/URAC (URAC) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Community Health Accreditation Program (CHAP) National Committee for Quality Assurance (NCQA)

7. 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.

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8.

American Accreditation HealthCare Commission/URAC (URAC) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Community Health Accreditation Program (CHAP) National Committee for Quality Assurance (NCQA)













8. Patient safety and medical errors are important concerns for both quality management (QM) and risk management. The following statement(s) can correctly be made about medical errors:

1. The complexity of modern medicine and healthcare delivery systems increases patients’ exposure to the risks of medical errors

2. Licensing boards for healthcare professionals in all states provide a consistent system of quality oversight and accountability

3. Provider compliance with internal incident reporting requirements is low

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All of the above 1 and 2 only 1 and 3 only 3 only

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1 D2 B3 A4 D5 A6 D7 A8 C



Reading 3B: Quality Assessment

Describe the major components of a quality assessment program Describe the methods health plans use to identify and prioritize key services and processes Identify the types of standards and indicators used in performance measurement Identify the three main types of performance measures and describe their advantages and disadvantages Explain the importance of case mix/severity adjustment Describe the types and sources of data needed to measure performance Describe the use of plan and provider report cards Identify some of the major issues and barriers in performance measurements


3. Click Complete the Test to score your answers and view a report. 1. 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.

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2.

In some instances, relatively inexpensive processes can qualify as high-cost processes. Each process must be classified into a single category. High-risk processes most often involve medical interventions or treatment plans for acute illnesses or case management processes for complex conditions. Administrative processes such as scheduling appointments are examples of high-volume processes.

2. 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

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3.

high-risk processes high-volume processes problem-prone processes high-cost processes

3. The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph. Each quality standard used by a health plan is associated with quality indicators. A ______________ indicator is a form of aggregate data indicator that produces results that fit within a specified range, such as the length of time to schedule an appointment.

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4.

yes/no










sentinel event discrete variable continuous variable

4. 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

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5.

clarity reliability validity feasibility

5. The following statement(s) can correctly be made about performance measurement systems:

1. The most difficult purpose for a performance measurement system to address is to measure changes in outcomes caused by modifications in administrative or clinical treatment processes

2. A health plan needs different performance measurement systems to evaluate its administrative services and the clinical performance of its providers

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6.


6. Health plan performance measures include structure measures, process measures, and outcome measures. The following statements are about the characteristics of these three types of performance measures. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

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7.

The most widely used structure measures relate to physician education and training. One advantage of structure measures over process measures is that structures are often linked directly to healthcare outcomes. Process measures are useful in identifying underuse, overuse, and inappropriate use of services. One disadvantage of outcome measures is that they can be influenced by factors outside the control of the health plan.

7. A health plan’s choice of structure measures, process measures, and outcome measures to evaluate performance depends in part on the scientific soundness of the measures. One approach that a health plan can use to enhance scientific soundness is stratification, which refers to the

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8.













identification and removal of unusual cases, such as patients with contraindications to a particular treatment, from consideration statistical adjustment of outcome measures to account for differences in the severity of illness or the presence of other medical conditions specification of a target population for a procedure and the data collection and analysis methods to be used elimination of variation within a patient population by dividing the population into groups that are at a similar level of risk

8. To measure performance for quality management, health plans collect and analyze three types of data: financial data, clinical data, and customer satisfaction data. The following statement(s) can correctly be made about the sources of clinical data:

1. Patient surveys are the most widely used source of disease-specific clinical information

2. Outcomes research studies sponsored by academic institutions and professional organizations have limited usefulness for particular health plans or individual providers

3. The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys address both physical and mental health status

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9.


9. 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

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that they are focused primarily on health maintenance organization (HMO) plans that they are based on data collected for the Health Plan Employer Data and Information Set (HEDIS) 3.0 that they are used to rank the performance of various health plans all of the above

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Reading 3C: Quality Improvement

Identify the major components of the performance improvement cycle Describe how health plans use benchmarking to guide quality improvement activities Identify the goals of member education and outreach programs Describe the techniques health plans use to improve providers' ability to work within the healthcare system Describe three tools health plans can use to support provider decision making and

improve clinical performance


3. Click Complete the Test to score your answers and view a report. 1. 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

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2.

both planned and controlled planned, but they are rarely controlled controlled, but they are rarely planned neither planned nor controlled

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

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3. achievable within a specified timeframe defined in terms of multiple results expressed in subjective, qualitative terms all of the above

3. Health plans communicate proposed performance changes through action statements. Select the answer choice containing an action statement that includes all of the required elements.

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4. The proportion of adult members who are screened for hypertension will increase by ten percent. Primary care providers (PCPs) will increase the proportion of children under the age of two who are up-to-date on immunizations by seven percent within one year. The QM program director will evaluate the level of provider compliance with clinical practice guidelines (CPGs). The disease management program director will increase participation by asthmatic children in the health plan’s pediatric asthma disease management program.

4. Administrative action plans are used when performance problems or Go to











opportunities are related to the way the organization itself operates. The following statement(s) can correctly be made about administrative action plans:

1. Administrative action plans allow health plans to coordinate management activities

2. One function of administrative action plans is to integrate service across all levels of the organization

3. Administrative action plans are designed to improve outcomes by helping plan members assume responsibility for their own health

question 5.

All of the above 1 and 2 only 1 and 3 only 2 and 3 only

5. As a follow-up to a performance improvement plan for member services, the Stellar Health Plan conducted an evaluation of the success of the plan. Stellar conducted its evaluation as the plan was being carried out. The evaluation focused on specific activities and assessed the relative importance of those activities to the plan as a whole. This information indicates that Stellar’s evaluation of the plan was both

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6.

concurrent and formative concurrent and summative retrospective and formative retrospective and summative

6. 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

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7. effectiveness is the relationship between what the organization puts into an improvement plan and what it gets out of the plan effectiveness is measured by reviewing outcomes to determine the accuracy or appropriateness of the strategy and the adequacy of resources allocated to that strategy the effectiveness of an action plan is typically measured with a concurrent evaluation an evaluation of plan effectiveness produces one of two results: the plan either (a) achieved the desired outcomes or (b) did not achieve the desired outcomes and is unlikely to do so under current conditions

7. The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the two terms or phrases that you have selected. The process for collecting and analyzing data differs for quality assessment (QA) and quality improvement (QI). For QA, data collection focuses on (objective / both objective and subjective) data, and data analysis identifies the (degree / cause) of variance.

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8.












objective / degree objective / cause both objective and subjective / degree both objective and subjective / cause

8. 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:

1. Inadequate staffing levels, employee errors, and equipment malfunctions are examples of special cause variance

2. Special cause variance is typically more difficult to detect and correct than is common cause variance

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9.


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

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10. cost-based benchmarking reveals why some areas of a health plan perform better or worse than comparable areas of other organizations diagnosis-related groups (DRGs) are a source of benchmarking data that describe individual procedures and cover both inpatient and outpatient care patient billing records provide a much more accurate account of procedure costs for benchmarking than do current procedural terminology (CPT) codes the focus of benchmarking for health plan has shifted from identifying the lowest cost practices to identifying best practices

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

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

11. 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

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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


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Assignment 4: Preventive Care, Self-Care, and Decision Support Programs

Reading 4A: Preventive Care Programs

Identify the three levels of preventive care Explain the role of health risk assessment (HRA) for preventive care Describe some strategies that health plans may use to enhance member

participation in preventive care programs


3. Click Complete the Test to score your answers and view a report. 1. 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

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2. develop an appropriate treatment strategy for patients whose conditions require extensive, complex healthcare educate and motivate members to prevent illness through their lifestyle choices prevent the occurrence of illness or injury detect a medical condition in its early stages and prevent or at least delay disease progression and complications

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

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3.

This questionnaire was designed specifically for use by health plans. Each health plan must use the same form of the questionnaire, with no additions or modifications. This questionnaire monitors the prevalence of the major behavioral risks associated with illness and injury among adults. All of the above statements are correct.

3. 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

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4.

Health plans rarely delegate HRA activities to external entities Health plans typically focus their HRA efforts on newly enrolled members HRA focuses on clinical data for an entire population and does not include demographic information that might identify individual members HRA is generally a reliable predictor of medical resource utilization

4. When analyzing and applying HRA results, the Multistate Health Plan Go toquestion












noted sampling bias. This information indicates that the HRA results 5. do not accurately depict the characteristics of the Multistate member population under study because of errors in data collection are more accurate for individual Multistate members than they are for the total population cannot be stated in numerical terms indicate variation in the number, types, and severity of behavioral risks presented by Multistate’s members

5. Determine whether the following statement is true or false: Immunization programs are a direct means of reducing health plan members’ needs for healthcare services and are typically cost-effective.

Go toquestion

6.

True False

6. Readiness is an important consideration for the development of health promotion programs. Readiness refers to

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7. the availability of previously established health promotion programs to an health plan’s members through employers, providers, or community service agencies the appropriateness of a program’s educational approach, given the language, literacy level, and cultural sensitivities of the target population a member’s level of knowledge about existing health risks and problems and the member’s ability and willingness to adopt new health-related behaviors a member’s access to information technology, such as a video cassette recorder, a computer, or the Internet

7. 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

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>---------- End of the Test ----------<1 D2 C3 B4 A










5 A6 C7 A

Reading 4B: Self-Care and Decision Support Programs

Describe the use of telephone triage services in self-care and decision support programs Identify general methods that health plans use to evaluate the effectiveness of preventive care, self-care, and

decision support programs Discuss the use of integration and partnerships to improve preventive care, self-

care, and decision support programs


3. Click Complete the Test to score your answers and view a report. 1. 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.

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2.

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. Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day. Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility. Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.

2. To improve members’ abilities to make appropriate care decisions about specific medical problems, some health plans use a form of decision support known as telephone triage programs. The following statements are about telephone triage programs. Select the answer choice containing the correct statement.

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3.

The primary role of telephone triage clinical staff is to diagnose the caller’s condition and give medical advice. Quality management (QM) for telephone triage programs typically focuses on the clinical information provided rather than on the quality of service. Currently, none of the major accrediting agencies offers an accreditation program specifically for telephone triage programs. A telephone triage program may also include a self-care component.

3. Emilio Martinez, a member of the Bloom Health Plan, has recently been diagnosed with prostate cancer by his physician, Dr. Robert Cohen. Mr. Martinez has decided to participate in Bloom’s shared decision-making program for prostate cancer. On the basis of this information, it is most likely correct to say

1. That verification of Mr. Martinez’s understanding about his care options protects both Dr. Cohen and Bloom against charges of

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malpractice

2. That Mr. Martinez and Dr. Cohen will discuss the care options available to Mr. Martinez, but the ultimate decision about care is up to Dr. Cohen


>---------- End of the Test ----------<

1 A2 D3 B

Assignment 5: Utilization Review

Reading 5A: Utilization Review

Discuss some of the key issues health plans must address to develop and maintain effective utilization review programs

Explain the importance of medical necessity, medical appropriateness, and utilization review process Describe the role of authorizations and member appeals in the utilization review process Identify some of the ways that health plans evaluate the results of utilization

review programs


3. Click Complete the Test to score your answers and view a report. 1. 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.

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

2. The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen. One component of UR is an administrative review. An administrative review compares the proposed medical care to the applicable (medical policy / contract provision). This type of review (can / cannot) be conducted by a nonclinical staff member.

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3.

medical policy / can medical policy / cannot contract provision / can contract provision / cannot

3. The Brighton Health Plan regularly performs prospective UR for surgical procedures. Brighton’s prospective UR activities are likely to include

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4. documenting the clinical details of the patient’s condition and care tracking the length of inpatient stay completing the discharge planning process determining the most appropriate setting for the proposed course of care










4. The following statement(s) can correctly be made about utilization guidelines:

1. When developing utilization guidelines, health plans balance evidence-based criteria with experience-based criteria

2. Utilization guidelines indicate when a UR nurse should refer a decision to a physician reviewer

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5.


5. 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.

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6.

True False

6. The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen. Due to competitive pressures and consumer demand, many health plans now offer direct access or open access products. Under a direct access product, a member is (required / not required) to select a primary care provider (PCP), and is (required / not required) to obtain a referral from a PCP or the health plan before visiting a network specialist.

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7.

required / required required / not required not required / required not required / not required

7. The following statements are about health plans' complaint resolution procedures (CRPs). Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

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8.

An health plan's CRPs reduce the likelihood of errors in decision making. CRPs typically provide for at least two levels of appeal for formal appeals. CRPs include only formal appeals and do not apply to informal complaints. Most complaints are resolved without proceeding through the entire CRP process.













8. Helath plans have a specified number of working days to respond to Level One appeals, as stated by company policy or regulatory requirements. With regard to the timeframes for appeals, it is generally correct to say

1. That the typical timeframe requires a health plan to respond to appeals in fewer than 20 days

2. That the timeframe is accelerated for expedited appeals

3. That the review period begins when the appeal arrives at a health plan

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9.


9. Determine whether the following statement is true or false: 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.

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10.

True False

10. Patricia McLeod is a member of the Enterprise Health Plan, which operates in State X. Ms. McLeod is scheduled to undergo a unilateral mastectomy for the treatment of breast cancer. The surgical procedure will be performed by Dr. Kim Lee, a surgical oncologist. Based on Enterprise’s medical policy, the contract with the purchaser, and Ms. McLeod’s medical condition, Enterprise’s UR staff have determined that the appropriate course of care for Ms. McLeod includes a 24-hour stay in the hospital following her surgery. State X, however, has a benefit mandate specifying health plan coverage for 48 hours of inpatient post-mastectomy care. In this situation, the length of hospital stay for which Enterprise must offer coverage is

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11.

the length of stay deemed appropriate by Dr. Lee the 24-hour stay determined to be appropriate by Enterprise’s UR staff the length of stay deemed appropriate by Ms. McLeod the 48-hour length of stay specified by State X

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

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indicate changes in the total amount of medical expenses or claim dollars paid for particular procedures measure the number of services provided per 1,000 members per year indicate standard approaches to care for many common, uncomplicated healthcare services report the number of times that a particular provider performs or recommends a service excluded from the benefit plan












>---------- End of the Test ----------<

1 C2 C3 D4 A5 A6 B7 C8 D9 B10 D11 B

Assignment 6: Case Management

Reading 6A: Case Management

Describe a variety of case management activities Explain the steps of the case management process Identify several strategic issues that may affect the development and improvement of case management programs Discuss the impact of legal issues, regulations, and accrediting agencies on case

management functions


3. Click Complete the Test to score your answers and view a report. 1. For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. In most commercial health plans, the case management process is directed by a case manager whose responsibilities typically include

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2.

focusing on a disabled member’s vocational rehabilitation and training approving all care decisions for patients under case management reducing the fragmentation of care that often results when individuals obtain services from several different providers all of the above

2. 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

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3.


3. Determine whether the following statement is true or false: The utilization review (UR) process produces the greatest number of case management referrals.

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4.

True False










4. Breanna Osborn is a case manager for a regional health plan. One component of Ms. Osborn’s job is the collection and evaluation of medical, financial, social, and psychosocial information about a member’s situation. This component of Ms. Osborn’s job is known as

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5.

case identification case management planning healthcare coordination case assessment

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.

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6. The use of a signed consent authorization form is consistent with accrediting agency standards for patient privacy and confidentiality of medical information. Case management that is initiated after a member has incurred substantial medical expenses is more likely to be viewed as a tool to cut costs rather than to improve outcomes. Health plan documents indicating that any case management delegates are separate, independent entities may reduce an health plan's exposure to risk. A case management file cannot be used to support the health plan's position in the event of a lawsuit.

6. The case management program director at the Nova Health Plan calculated the program’s ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:

Administrative costs for case management ..........$40,000Actual medical care expenses for patients under case management ..........$680,000Projected medical care expenses for the same patients without case management ..........$900,000

This information indicates that, for the previous quarter, Nova’s ratio of medical expense savings to case management administrative costs was

Go toquestion

7.

0.71/1 0.80/1 5.50/1 1.25/1

7. One true statement about state regulation of case management activities is that the majority of states

Go toquestion

8. have enacted laws that list specific quality management requirements for a case management program consider case management files to be medical records that must be retained for a specified length of time view case management similarly and follow similar patterns with their laws and regulations













have enacted laws or regulations requiring licensure or certification of case managers

8. The American Accreditation HealthCare Commission/URAC (URAC) has an accreditation program specifically for case management services. From the answer choices below, select the response that correctly identifies the type(s) of case management services addressed by URAC’s standards and the type(s) of organizations to which these standards may be applied.

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Type(s) of Services-on-site services only Type(s) of Organization-health plans only Type(s) of Services-on-site services only Type(s) of Organization-any organization that performs case management functions Type(s) of Services-both telephonic and on-site services Type(s) of Organization-health plans only Type(s) of Services-both telephonic and on-site services Type(s) of Organization-any organization that performs case management functions

>---------- End of the Test ----------<

1 C2 D3 A4 D5 D6 C7 B8 D



Assignment 7: Disease Management

Reading 7A: Disease Management

Distinguish between disease management and case management Explain why health plans establish disease management programs Describe the types of organizations that provide disease management Explain the decisions a health plan must make to implement a disease management program Describe four approaches to integrating information disease management

programs


3. Click Complete the Test to score your answers and view a report. 1. The following statements are about disease management programs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

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2. The focus of disease management is on responding to the needs of individual members for extensive, customized healthcare supervision. Disease management programs serve to improve both clinical and financial outcomes for healthcare services related to chronic conditions. Tools such as preventive care, self-care, and decision support programs are used to support both case management and disease management. Disease management programs apply to both diseases and medical conditions that are not diseases, such as high-risk pregnancy, severe burns, and trauma.

2. Determine whether the following statement is true or false: Under a carve-out arrangement for disease management, patients typically maintain their existing relationships with primary care providers (PCPs) for all care, including disease management.

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3.

True False

3. Comorbidity can have a significant impact on the effective implementation of disease management programs. Comorbidity can correctly be defined as the

Go toquestion

4.

degree to which the progression of a disease or condition is understood prevalence or rate of a sickness or injury within a given population degree of severity of a particular disease or condition presence of a chronic condition or added complication other than the condition that requires medical treatment

4. 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.

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5.













Varga’s overall care plan. This information indicates that Ms. Varga is participating in the type of disease management program known as a

coordinated outreach model program case management model program hub-and-spoke model program group clinic model program

5. 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

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6. combines all existing information from all data sources into a single comprehensive system connects multiple databases with a central interface engine that acts as an information clearinghouse provides an outside vendor with pertinent data that the vendor compiles into an integrated database creates a separate database that pulls pertinent information from the health plan’s claims database, formats the information for easy analysis, and stores it in the separate database

6. The Carlyle Health Plan uses the following clinical outcome measures to evaluate its diabetes and asthma disease management programs:

Measure 1: The percentage of diabetic patients who receive foot exams from their providers according to the program’s recommended guidelines Measure 2: The number of asthma patients who visited emergency departments for acute asthma attacks

From the answer choices below, select the response that correctly identifies whether these measures are true outcome measures or intermediate outcome measures. Measure 1- Measure 2-

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7.

Measure 1-true outcome measure Measure 2-true outcome measure Measure 1-true outcome measure Measure 2-intermediate outcome measure Measure 1-intermediate outcome measure Measure 2-true outcome measure Measure 1-intermediate outcome measure Measure 2-intermediate outcome measure

7. Determine whether the following statement is true or false: Participation in disease management programs is currently voluntary.

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True False

>---------- End of the Test ----------<

1 A2 B3 D4 B









5 D6 C7 A

Assignment 8: Medical Management Considerations for Different Levels of Care

Reading 8A: Medical Management Strategies for Acute Care

Describe the potential benefits and drawbacks of using hospitalists for the management of inpatient acute care Explain why the utilization of emergency services is an ongoing concern for health plans and describe some

approaches that health plans may use to improve utilization management for emergency care Explain how clinical pathways are useful medical management tools and how health plans facilitate development of

them Define the term center of excellence and describe how its use may benefit health

plan medical management programs


3. Click Complete the Test to score your answers and view a report.

1. Acute care refers to healthcare services for medical problems that Go to

question 2.

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

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

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3. A patient who has been transferred to a hospitalist for management of inpatient care usually continues to receive care from the hospitalist after discharge. Hospitalists are used primarily to manage care for obstetric, pediatric, and oncology patients. In order to serve as a hospitalist, a physician must have a background in critical care medicine. Hospitalists typically spend at least one-quarter of their time in a hospital setting.

3. 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

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4.

All of the above 1 and 2 only










1 and 3 only 2 only

4. 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

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5.

1—2—3 2—3—1 3—1—2 3—2—1

5. 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.

Go toquestion

6.

utilization management standards the prudent layperson standard preauthorization diagnosis-based retrospective review

6. 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

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7.

specialty referral primary prevention urgent care emergency care

7. 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

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8.

resulted in unnecessarily expensive charges for treatment













prevented Ms. Newman from receiving immediate attention for her condition gave Ms. Newman access to more effective and efficient treatment than she could have obtained from other providers in the same region allowed clinical staff an opportunity to determine whether Ms. Newman required hospitalization without actually admitting her

8. 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

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9. determine which healthcare services are medically necessary and appropriate for a particular patient in a particular situation 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 cover only services delivered in an acute inpatient setting address medical conditions that affect a small segment of a given population and with which the majority of providers are unfamiliar

9. In order to be effective, a clinical pathway must improve quality and decrease costs.

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10. True False

10. 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

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base pathways on relevant evidence reported in medical literature restrict each pathway to a single medical condition use pathways to establish a new standard of care allow providers to use only those interventions listed in the pathways

>---------- End of the Test ----------<

1 C2 D3 A4 D5 B6 C7 D8 B9 B10 A









Reading 8B: Medical Management Strategies for Post-Acute Care

Identify and describe the purposes of four types of post-acute care Explain how subacute care differs from skilled care Explain two types of advance directives Describe the role of a health plan in end-of-life care


3. Click Complete the Test to score your answers and view a report. 1. The case management team at the Hightower Health Plan reviewed the medical records of the following two plan members to determine the type of care each one needs and the most appropriate setting for that care:

Ira Morton was hospitalized for a severe stroke. Although his medical condition is stable, the stroke left him partially paralyzed and he will require extensive rehabilitation and 24-hour medical care.

Theresa Finley is recovering from a total hip replacement and is in need of short-term physical therapy and twice-weekly visits from a licensed nurse to check her blood pressure and the healing of her incision.

From the answer choices below, select the response that correctly identifies the level of care that would be most appropriate for Mr. Morton and Ms. Finley.

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2.

Mr. Morton-acute care Ms. Finley-subacute care Mr. Morton-palliative care Ms. Finley-acute care Mr. Morton-subacute care Ms. Finley-skilled care Mr. Morton-skilled care Ms. Finley-palliative care

2. 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

Go toquestion

3.

National Committee for Quality Assurance (NCQA) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) American Accreditation HealthCare Commission/URAC (URAC) Foundation for Accountability (FACCT)

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 you have chosen. A primary distinction between skilled care and subacute care relates to the extent and medical complexity of the patient’s needs. Generally, subacute care patients require (more / fewer) services from physicians and nurses and (more / less) extensive rehabilitation services than do skilled care patients.

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4.










more / more more / less fewer / more fewer / less

4. Skilled nursing facilities (SNFs) are required by law to have formal programs for quality improvement and to monitor these programs using established standards. These requirements are described in

1. The Omnibus Budget Reconciliation Act (OBRA) of 1986

2. The Balanced Budget Act (BBA) of 1997

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5.

Both 1 and 2 1 only 2 only Neither 1 or 2

5. Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans typically use home healthcare include

1. The period prior to a hospital admission

2. The period following discharge from a hospital

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6.


6. Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide should Mr. Farrell become incapacitated. The document that Mr. Farrell is using to communicate his end-of-life healthcare wishes to his family is known as a

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7.

medical power of attorney patient assessment and care plan living will healthcare proxy

7. Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to

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avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide should Mr. Farrell become incapacitated.

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.

Decisions regarding Mr. Farrell’s end-of-life care are legally the right and responsibility of

Mr. Farrell and his family Mr. Farrell’s physician Mr. Farrell’s health plan all of the above

>---------- End of the Test ----------<

1 C2 B3 A4 B5 A6 C7 A

Assignment 9: Medical Management Considerations for Pharmacy and Specialty Services

Reading 9A: Medical Management for Pharmacy Services-Part I

Describe some of the advantages and disadvantages of using pharmacy benefit managers (PBMs) to develop and manage pharmacy benefit programs

Identify strategies that health plans can use to manage the way medications are priced and prescribed Describe three factors that impact prescription drug utilization Explain the difference between a two-tier and a three-tier copayment structure Describe five different types of analyses that are conducted in pharmoeconomic

research


3. Click Complete the Test to score your answers and view a report. 1. 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

1. Managing the costs of prescription drugs 2. Promoting efficient and safe drug use

3. Determining the health plan’s internal management responsibilities for pharmacy services

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2.


2. 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

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3.

limitations exceptions exclusions drug edits

3. The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen. The Millway Health Plan received a 15% reduction in the price of a particular pharmaceutical based on the volume of the drug Millway purchased from the manufacturer. This reduction in price is an example of a (rebate / price discount) and (is / is not) dependent on actual provider prescribing patterns.

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4.










rebate / is rebate / is not price discount / is price discount / is not

4. 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.

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5. Health plans typically use provider profiles to improve the quality of care associated with the use of prescription drugs. Provider profiles identify prescribing patterns that fall outside normal ranges. Health plans can motivate providers to change their prescribing patterns by sharing profile information with plan members and the general public. Provider profiles are effective in modifying individual prescribing patterns, but they have little effect on group prescribing patterns.

5. 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

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6.

detailing cognitive services counterdetailing drug efficacy study implementation (DESI)

6. 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

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7.

$5 $10 $25 $75

7. In recent years, the demand for prescription drugs has increased dramatically. Factors that have contributed to this increase include

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8. increased education regarding the purpose and benefits of drug formularies













reductions in the cost of prescription drugs increased use of direct-to-consumer (DTC) advertising all of the above

8. 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

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9.

cost-effectiveness analysis (CEA) cost-minimization analysis (CMA) cost-utility analysis (CUA) cost of illness analysis (COI)

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

Benefit CostDrug A $525 $350Drug B $450 $250Drug C $400 $200Drug D $350 $100According to this analysis, the drug that represents the most efficient use of resources is

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Drug A Drug B Drug C Drug D

>---------- End of the Test ----------<

1 B2 C3 D4 D5 C6 C7 C8 A9 D






Reading 9B: Medical Management for Pharmacy Services-Part II

List several functions that a health plan's pharmacy and therapeutics (P&T) committee performs List the five steps in performing DUR Describe the three types of DUR Explain the state laws related to mail-order pharmacies and generic substitution


3. Click Complete the Test to score your answers and view a report. 1. In most health plans, the formulary system is developed and managed by a P&T committee. The P&T committee is responsible for

Go toquestion

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

2. 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).

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3.

open / mandatory open / voluntary closed / mandatory closed / voluntary

3. 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.

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4.










If Ms. Stanley agrees to the generic substitution, she will receive a drug that has not been tested for safety and efficacy in large clinical trials is available without a prescription at a reasonable cost has been classified by the Food and Drug Administration (FDA) as safe, but that has not been proven fully effective contains active ingredients that are identical to those of the prescribed brand-name drug

4. Drugs included in a health plan’s formulary can be classified according to how freely they can be prescribed. By definition, a drug that requires some sort of review or approval by a plan physician or group of physicians before the prescription can be filled is

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5.

an unrestricted drug a monitored drug a restricted drug a conditional drug

5. 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

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6.

generic substitution, and prescriber approval is not required generic substitution, and prescriber approval is always required therapeutic substitution, and prescriber approval is not required therapeutic substitution, and prescriber approval is always required

6. 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

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7.


7. One method that health plans use to address provider compliance with formularies is academic detailing.

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8. True













False

8. One of the steps in drug utilization review (DUR) is defining optimal drug use, which can be accomplished by applying diagnosis criteria and drug-specific criteria. Drug-specific criteria are standards that identify the

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9. appropriate dosages, duration of treatment, and other elements related to the use of a particular drug actual prescribing and dispensing patterns for a particular drug types of diseases, conditions, or patients for which a drug should be used cost-effectiveness of all possible drug treatments for a particular condition

9. DUR can be conducted prospectively, concurrently, or retrospectively. One true statement about prospective DUR is that it

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10. involves periodic audits of the medical records of a certain group of patients is based on historical data focuses on the drug therapy for a single patient rather than overall usage patterns is conducted by physicians, without input from pharmacists

10. All states have laws describing the conditions under which pharmacists can substitute a generic drug for a brand-name drug. With respect to these laws, it is correct to say that in every state,

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11. pharmacists must obtain physician approval before substituting generics for brand-name drugs pharmacists must obtain authorization from the health plan before substituting generics for brand-name drugs prescribers must obtain authorization from the health plan before prescribing a brand-name drug prescribers have some mechanism that allows them to prevent pharmacists from substituting generics for brand-name drugs

11. PBMs are accredited by the same organizations that accredit health plans.

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True False

>---------- End of the Test ----------<1 A2 C3 D4 B5 D6 C7 A8 A9 C10 D












Reading 9C: Medical Management for Specialty Services

Explain why a health plan might choose to use a carve-out arrangement to deliver a specialty service Describe several medical management challenges for behavioral healthcare Explain the strategies that health plans and managed behavioral healthcare organizations use to manage quality and

costs for behavioral healthcare Understand quality and utilization management strategies for dental care, vision care, and complimentary and

alternative medicine


3. Click Complete the Test to score your answers and view a report. 1. 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

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2. involve the same types of providers and delivery systems as do standard medical services are a subset of a health plan’s standard medical-surgical services are not monitored by health plans for quality or utilization require specialized knowledge for service delivery and management

2. 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

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3.

remove behavioral healthcare services from the primary care setting shift behavioral healthcare from acute inpatient settings to alternative settings when feasible reserve the use of psychotherapy for treatment of those conditions that persist over long periods of time or for the life of the patient offer the same level of compensation to all of the professional disciplines that provide behavioral healthcare services to plan members

3. 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)

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4.

All of the above










1 and 2 only 2 and 3 only 1 only

4. The Mental Health Parity Act (MHPA) of 1996 is a federal law that establishes requirements for behavioral healthcare coverage for group plan members. The MHPA

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5. requires health plans to offer mental health benefits to all eligible members prohibits health plans that offer mental health benefits from imposing lower annual or lifetime dollar limits on mental illnesses than they do on physical illnesses provides an exemption for health plans that can demonstrate cost savings of more than 1 percent prohibits health plans from limiting the number of outpatient visits or inpatient days covered under the plan

5. The following statements are about medical management considerations for dental care. Select the answer choice containing the correct statement.

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6. Managed dental care organizations are regulated at the state rather than the federal level. Dental care differs from medical care in that most dental care is provided by specialists. Dental preferred provider organizations (Dental PPOs) are subject to more regulation than are dental health maintenance organizations (DHMOs). Managed dental plans are accredited by the National Association of Dental Plans (NADP).

6. Michelle Durden, who is enrolled in a dental health maintenance organizations (DHMO) offered by her employer, is due for a routine dental examination. If the plan is typical of most DHMOs, then Ms. Durden

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7.

must pay the entire cost of the examination must obtain a referral to a dentist from her primary care provider (PCP) can schedule the examination without preauthorization of payment by the DHMO can schedule an unlimited number of examinations and cleanings per year

7. Vision care is typically separated into two categories: routine eye care and clinical eye care. The standard benefit plans offered by most health plans include coverage for

1. Routine eye care

2. Clinical eye care

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8.

Both 1 and 2 1 only













2 only Neither 1 nor 2

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

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9. must be offered as separate supplemental benefits or separate products lack clinical trials to evaluate their safety and effectiveness are not covered by state or federal consumer protection statutes focus on a specific illness, injury, or symptom rather than on the whole body

9. Examples of alternative healthcare practitioners are chiropractors, naturopaths, and acupuncturists. The only well-established credentialing standards for alternative healthcare practitioners are those available from NCQA. These NCQA credentialing standards apply to

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10.

chiropractors naturopaths acupuncturists all of the above

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

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True False

>---------- End of the Test ----------<

1 D2 B3 B4 B5 A6 C7 C8 B9 A10 B









Assignment 10: Medical Management for Government-Sponsored Programs

Reading 10A: Medicare

Identify the major benefits of managed Medicare Understand the legal and regulatory requirements that affect medical management for Medicare Recognize the special health risk factors and needs of the Medicare population Describe the important components of a comprehensive program of geriatric care


3. Click Complete the Test to score your answers and view a report. 1. 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

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2.

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

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

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3. expand Medicare benefits by mandating coverage for certain preventive services reduce the number of organizations that can deliver covered services encourage growth of managed Medicare programs in all markets increase the number of “zero premium” plans available to Medicare beneficiaries

3. 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 and Medicare Services (CMS) initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standards apply to

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4.

standard medical-surgical services mental health and substance abuse services services offered to Medicare enrollees as optional supplementary benefits all of the above

4. Comparing the quality of managed Medicare programs with the quality of Go to











FFS Medicare programs is often difficult. Unlike FFS Medicare, managed Medicare programs

question 5.

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

5. 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

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6.

do not experience mental health problems consume more than half of all prescription drugs are likely to equate quality with the technical aspects of clinical procedures require longer and more costly recovery periods following acute illnesses or injuries than does the general population

6. 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).

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7.

activities of daily living / functional status activities of daily living / health status instrumental activities of daily living / functional status instrumental activities of daily living / health status

7. Health plans that offer healthcare programs for Medicare beneficiaries have a strong financial incentive for identifying high-risk seniors as early as possible. The identification of high-risk seniors is typically accomplished through the use of

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8.

case management geriatric evaluation and management (GEM) intervention identification interdisciplinary home care (IHC)

8. CMS has developed two prototype programs—Programs of All-inclusive Care for the Elderly (PACE) and the Social Health Maintenance Organization (SHMO) demonstration project—to deliver healthcare services to Medicare

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beneficiaries. From the answer choices below, select the response that correctly identifies the features of these programs.

PACE-annual limits on benefits for nursing home and community-based care SHMO-no limits on long-term care benefits PACE-provide long-term care only SHMO-provide acute and long-term care PACE-enrollees must be age 65 or older SHMO-enrollees must be age 55 or older PACE-enrollment open to nursing home certifiable Medicare beneficiaries only SHMO-enrollment open to all Medicare beneficiaries

>---------- End of the Test ----------<

1 C2 A3 D4 C5 D6 A7 C8 D

Reading 10B: Medicaid

Describe the impact of recent laws and regulations on the management of medical care for Medicaid recipients Describe the health risk factors and healthcare needs of Medicaid recipients Identify the essential components of an effective Medicaid health plan plan Describe the challenges health plans face in designing programs to meet the needs

of Medicaid recipients


3. Click Complete the Test to score your answers and view a report. 1. Recent laws and regulations have established new requirements for Medicaid eligibility. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 affected Medicaid eligibility by

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2.

severing the link between Medicaid and public assistance eliminating the need for applications for Medicaid and public assistance allowing states to provide healthcare benefits to groups outside the traditional Medicaid population providing supplemental funding for dual eligibles in the form of five-year block grants

2. The BBA of 1997 allows states to provide Medicaid benefits to children through the State Children’s Health Insurance Program (SCHIP). Under the terms of the BBA, states can implement SCHIP as

1. Part of their existing Medicaid programs

2. Separate commercial insurance programs

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3.


3. 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.

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4. QAPI provides separate sets of standards for Medicaid MCEs and Medicare+Choice plans. Medicaid primary care case management (PCCM) programs are required to comply with all QAPI standards. QISMC standards for quality measurement and improvement apply only to clinical services delivered to Medicare and Medicaid enrollees. States that require Medicaid MCEs to comply with QAPI standards are considered to be in compliance with CMS quality assessment and improvement regulations.










4. The Medicaid population can be divided into subgroups based on their relative size and the costs of providing benefits. From the answer choices below, select the response that correctly identifies the subgroups that represent the largest percentages of the total Medicaid population and of total Medicaid expenditures. Largest % of Medicaid Population- Largest % of Medicaid Expenditures-

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5.

Largest % of Medicaid Population-dual eligibles Largest % of Medicaid Expenditures-children and low-income adults Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for MedicareLargest % of Medicaid Expenditures-dual eligibles Largest % of Medicaid Population-children and low-income adults Largest % of Medicaid Expenditures-chronically ill or disabled individuals not eligible for Medicare Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for Medicare Largest % of Medicaid Expenditures-children and low-income adults

5. The following statements are about chronic and disabling conditions among children eligible for Medicaid. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

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6. Children with chronic conditions use more physician and nonphysician professional services than do children in the general population. The majority of chronic conditions affecting children in Medicaid programs are the same as those affecting children in the general population. Medicaid-eligible children are at risk for serious mental and physical conditions. Children in Medicaid programs have a higher incidence of chronic disabling conditions than do children in the general population.

6. Determine whether the following statement is true or false: The key to successfully managing the quality and cost-effectiveness of healthcare services for Medicaid enrollees is to merge Medicaid recipients into existing plans.

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7.

True False

7. Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the

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lack of qualified providers in provider networks lack of resources necessary to establish case management programs for patients with complex conditions unstable eligibility status of Medicaid recipients inability of Medicaid recipients to change health plans or PCPs

>---------- End of the Test ----------<












1 A2 A3 D4 C5 B6 B7 C

Reading 10C: Other Government-Sponsored Healthcare Programs

Identify several FEHBP requirements that impact a health plan's medical management activities Describe how the Military Health System and the Veterans Health Administration influence healthcare quality and

cost in the private sector, and vice versa Discuss key differences between workers' compensation programs and group healthcare programs in terms of

quality management and cost management.


3. Click Complete the Test to score your answers and view a report. 1. 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

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2.


2. Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located at a military installation. Ms. Wilson serves as a primary point of contact between enrollees and the TRICARE system and answers enrollees’ questions about plan options, eligibility, provider selection, and claims. This information indicates that Ms. Wilson serves as a

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3.

lead agent beneficiary services representative health plan support contractor primary care manager (PCM)

3. 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).

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4.










appeals / TRICARE contractor appeals / Area Field Office grievances / TRICARE contractor grievances / Area Field Office

4. The delivery of quality, cost-effective healthcare is a primary goal of both group healthcare and workers’ compensation programs. One difference between group healthcare and workers’ compensation is that workers’ compensation

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5.

provides health and disability benefits to employees injured on the job only if the employer is at fault for the injury provides coverage for a variety of direct and indirect healthcare, disability, and workplace costs manages costs by including employee cost-sharing features in its benefit design places limits on benefits by restricting the amount of benefit payments or the number of covered hospital days or provider office visits

5. For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. Ways that workers’ compensation health plans can help control the costs of job-related injuries and illnesses include

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6.

applying strict definitions of medical necessity developing prevention and recovery programs applying out-of-network benefit reductions all of the above

6. 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

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increases administrative costs requires plans to maintain separate databases of patient care information exempts plans from complying with state workers’ compensation regulations allows plans to apply disability management and return-to-work techniques to nonoccupational conditions

>---------- End of the Test ----------<

1 A2 B3 A4 B5 B6 D









ahm 540 - tests

Documents

role of medical management

term medical management

role of information

following activities

health plan functions

riverside health plan

correct answer choice

health plans members