AHIP AHM-540 - Medical Management

The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

Medical management programs often require the analysis of many types of data and information. __________________ is an automated process that analyzes variables to help detect patterns and relationships in the data.

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

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.

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

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

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.

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

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

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

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