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AHIP AHM-540 - Medical Management

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Total 163 questions

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

A.

lack of qualified providers in provider networks

B.

lack of resources necessary to establish case management programs for patients with complex conditions

C.

unstable eligibility status of Medicaid recipients

D.

inability of Medicaid recipients to change health plans or PCPs

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.

A.

A letter of intent is the contractual document that describes the delegated functions and the responsibilities of the MCO and the delegate.

B.

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.

C.

Under most delegation agreements, an MCO cannot terminate the agreement before the end date stated in the agreement.

D.

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.

Determine whether the following statement is true or false:

Participation in disease management programs is currently voluntary.

A.

True

B.

False

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

A.

determine which healthcare services are medically necessary and appropriate for a particular patient in a particular situation

B.

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

C.

cover only services delivered in an acute inpatient setting

D.

address medical conditions that affect a small segment of a given population and with which the majority of providers are unfamiliar

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

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.

A.

objective / degree

B.

objective / cause

C.

both objective and subjective / degree

D.

both objective and subjective / cause

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.

A.

This questionnaire was designed specifically for use by health plans.

B.

Each health plan must use the same form of the questionnaire, with no additions or modifications.

C.

This questionnaire monitors the prevalence of the major behavioral risks associated with illness and injury among adults.

D.

All of the above statements are correct.

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

A.

do not experience mental health problems

B.

consume more than half of all prescription drugs

C.

are likely to equate quality with the technical aspects of clinical procedures

D.

require longer and more costly recovery periods following acute illnesses or injuries than does the general population