NEW QUESTION 1
In order to be effective, a clinical pathway must improve quality and decrease costs.

• A. True
• B. False

Answer: B

NEW QUESTION 2
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.

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

Answer: D

NEW QUESTION 3
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

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

Answer: D

NEW QUESTION 4
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.

• A. yes/no
• B. sentinel event
• C. discrete variable
• D. continuous variable

Answer: D

NEW QUESTION 5
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.

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

Answer: D

NEW QUESTION 6
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

• A. 1—2—3
• B. 2—3—1
• C. 3—1—2
• D. 3—2—1

Answer: D

NEW QUESTION 7
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

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

Answer: D

NEW QUESTION 8
One way that health plans evaluate their UR programs is by monitoring utilization rates. By definition, utilization rates typically

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

Answer: B

NEW QUESTION 9
To see that utilization guidelines are consistently applied, UR programs rely on authorization systems. Determine whether the following statement about authorization systems is true or false:
Only physicians can make nonauthorization decisions based on medical necessity.

• A. True
• B. False

Answer: A

NEW QUESTION 10
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

• A. that the construction of a data warehouse is quick and simple
• B. that a data warehouse addresses the problems associated with multiple data management systems
• C. that a data warehouse stores only current data
• D. all of the above

Answer: B

NEW QUESTION 11
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

• A. medical power of attorney
• B. patient assessment and care plan
• C. living will
• D. healthcare proxy

Answer: C

NEW QUESTION 12
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).

• A. activities of daily living / functional status
• B. activities of daily living / health status
• C. instrumental activities of daily living / functional status
• D. instrumental activities of daily living / health status

Answer: A

NEW QUESTION 13
Most health plans require a PCP referral or precertification for CAM benefits.

• A. True
• B. False

Answer: B

NEW QUESTION 14
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

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

Answer: D

NEW QUESTION 15
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

• A. limitations
• B. exceptions
• C. exclusions
• D. drug edits

Answer: C

NEW QUESTION 16
The following statement(s) can correctly be made about the characteristics of peer review:
* 1.Peer review is applicable to either single episodes of care or to entire programs of care
* 2.Most peer review is conducted concurrently
* 3.Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services furnished to Medicare and Medicaid recipients enrolled in health plans

• A. All of the above
• B. 1 and 2 only
• C. 1 and 3 only
• D. 2 and 3 only

Answer: C

NEW QUESTION 17
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

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

Answer: C

NEW QUESTION 18
Selene Varga is participating in her health plan’s disease management program for congestive heart failure. Ms. Varga’s health status is regularly monitored and managed by a licensed nurse who visits Ms. Varga at her home to administer treatment and assess the need for changes in Ms. Varga’s overall care plan. This information indicates that Ms. Varga is participating in the type of disease management program known as a

• A. coordinated outreach model program
• B. case management model program
• C. hub-and-spoke model program
• D. group clinic model program

Answer: B

NEW QUESTION 19
Readiness is an important consideration for the development of health promotion programs. Readiness refers to

• A. the availability of previously established health promotion programs to an health plan’s members through employers, providers, or community service agencies
• B. the appropriateness of a program’s educational approach, given the language, literacy level, and cultural sensitivities of the target population
• C. 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
• D. a member’s access to information technology, such as a video cassette recorder, a computer, or the Internet

Answer: C

NEW QUESTION 20
In recent years, the demand for prescription drugs has increased dramatically. Factors that have contributed to this increase include

• A. increased education regarding the purpose and benefits of drug formularies
• B. reductions in the cost of prescription drugs
• C. increased use of direct-to-consumer (DTC) advertising
• D. all of the above

Answer: C

NEW QUESTION 21
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