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AHIP AHM-540 - Medical Management

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Total 163 questions

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

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

A.

Both 1 and 2

B.

1 only

C.

2 only

D.

Neither 1 nor 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

A.

based on Web-based technologies

B.

available only to the employees of the health plan

C.

publicly available, so the potential exists for unauthorized access to a health plan’s proprietary systems

D.

used to handle the majority of health plan eCommerce

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

A.

medical policy evaluates clinical services against specific benefits language rather than against scientific evidence

B.

benefits administration policy determines whether a particular service is experimental or investigational

C.

benefits administration policy focuses on both clinical and nonclinical coverage issues

D.

administrative policy contains the guidelines to be followed when handling member and provider complaints and disputes

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

A.

both Medicare+Choice plans and Medicaid health plans

B.

Medicare+Choice plans only

C.

Medicaid health plans only

D.

neither Medicare+Choice plans nor Medicaid health plans

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

A.

case identification

B.

case management planning

C.

healthcare coordination

D.

case assessment

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

A.

Health Resources and Services Administration (HRSA)

B.

Office of Personnel Management (OPM)

C.

Department of Health and Human Services (HHS)

D.

Department of Justice (DOJ)

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

A.

focusing on a disabled member’s vocational rehabilitation and training

B.

approving all care decisions for patients under case management

C.

reducing the fragmentation of care that often results when individuals obtain services from several different providers

D.

all of the above

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.

A.

A primary goal of UR is to address practice variations through the application of uniform standards and guidelines.

B.

UR evaluates whether the services recommended by a member’s provider are covered under the benefit plan.

C.

UR recommends the procedures that providers should perform for plan members.

D.

A health plan’s UR program is usually subject to review and approval by the state insurance and/or health departments.

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

A.

provides an absolute measure of treatment results, whereas clinical research provides a relative measure of results

B.

focuses on treatment effectiveness, whereas clinical research focuses on treatment efficacy

C.

examines diseases and treatments in isolation, whereas clinical research considers the effects of changes in health status and quality of life

D.

gathers outcomes data from controlled clinical trials, whereas clinical research collects and analyzes clinical, financial, and administrative data