AHM-250 Healthcare Management: An Introduction Question and Answers

National Committee for Quality Assurance (NCQA)

American Accreditation HealthCare Commission/URAC Of these organizations, performance data is included i

A only

B only

A and B

none of the above

a data warehouse

a decision support system

an outsourcing system

an electronic medical record (EMR) system

emphasized compensating physicians based solely on the volume of medical services they provide

exempted HMOs from all state licensure requirements

established a process under which HMOs could elect to be federally qualified

required federally qualified HMOs to relate premium levels to the health status of the individual enrollee or employer group

Unlike a consolidated medical group, physicians in a 'Clinic without walls' maintain their practices independently in multiple locations.

Unlike a consolidated medical group, a 'Clinic without walls' performs or arranges for business operations for the member physicians.

Both A & B

Manor's system is best described as an automated call distributor (ACD).

Both Manor's system and Squire's device are applications of computer/telephone integration (CTI).

Squire's device is best described as an interactive voice response (IVR) system.

All of these statements are correct.

As a result of the Balanced Budget Refinement Act (BBRA), PPOs are required to meet all QISMC quality requirements.

QISMC standards typically do not apply to such Medicare services as mental health or substance abuse services.

Medicaid primary care case manager (PCCM) programs are subject to the same QISMC quality standards and performance measures as are all other Medicare and Medicaid programs.

QISMC standards and guidelines are required for Medicare MCOs, but they are applicable to Medicaid MCOs at the discretion of the individual states.

must comply with all state-mandated benefits and provider requirements

must offer each of its enrollees a Medicare supplement

places primary care t the censer of the delivery system and focuses on managing patient care at all levels

most likely must cover Medicare Part A, but not Medicare Part B, benefits

At the end of a rating period, the financial gains and losses experienced by the group during that rating period and, if the group's experience during the period is better than expected, refund part of the group's premium in the form of an experience ratio

Use Robust's average experience with all groups to calculate this particular group's premium.

Use the group's past experience to estimate the group's expected experience for the next period.

All of the above

Notify customers of any sharing of non-public personal financial information with nonaffiliated third parties.

Prohibit customers from having the opportunity to 'opt-out' of sharing non-public personal financial information.

Disclose to affiliates, but not to third parties, their privacy policies regarding the sharing of nonpublic personal financial information.

Agree not to disclose personally identifiable financial information or personally identifiable health information.

Health plans and their providers are obligated not to harm their members

Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a group

Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members

Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives

True

False

Low or stable costs.

Appropriate, rather than inappropriate, utilization rates.

A benefit that cannot be easily defined.

Defined patient population.

a traditional HMO plan

a managed indemnity plan

a point of service (POS) option

an exclusive provider organization (EPO)

The Serenity Healthcare Organization requires a plan member or the provider in charge of the member's care to obtain authorization for inpatient care before the member is admitted to the hospital.

UR nurses employed by the Friendship Health Plan monitor length of stay to identify factors that might contribute to unnecessary hospital days.

The Optimum Health Group evaluates the medical necessity and appropriateness of proposed services and intervenes, if necessary, to redirect care to a more appropriate care setting.

The Axis Medical Group examines provider practice patterns to identify areas in which services are being underused, overused, or misused and designs strategies to prevent inappropriate utilization in the future.

Standard (pure) community rating is typically used for large groups because it is the most competitive rating method for large groups.

Under standard (pure) community rating, a health plan charges all employers or other group sponsors the same dollar amount for a given level of medical benefits or health plan, without adjusting for factors such as age, gender, or experience.

In using the adjusted community rating (ACR) method, a health plan must consider the actual experience of a group in developing premium rates for that group.

The Centers for Medicare and Medicaid Services (CMS) prohibits health plans that assume Medicare risk from using the adjusted community rating (ACR) me

The GLB Act allows convergence among the transaction

A only

Both A and B

B only

Neither A nor B

The nature, quantity, and quality of the resources that a health plan has available for member service and patient care.

The methods and procedures a health plan and its providers use to furnish service and care.

The extent to which services succeed in improving or maintaining satisfaction and patient health.

None of the above

State that Dr. Aldridge's provider contract with Badger will automatically terminate if he loses his medical license or hospital privileges.

Specify a time period during which the party that breaches the provider contract must remedy the problem in order to avoid termination of the contract.

Give Dr. Aldridge the right to appeal Badger's decision if he is terminated with cause from Badger's provider network.

Specify that Badger can terminate this provider contract without providing a reason, but only if Badger gives Dr. Aldridge at least 90-days' notice of its intent to terminate the contract.

Prospective review

Concurrent review

A, B, and C

A and B only

A and C only

B only

random change

structural change

haphazard change

reactive change

A, B, C, and D

A and C only

A, B, and D only

B, C, and D only

278

397

403

920

branding

positioning

database marketing

personal selling

$300

$510

$600

$810

The initial ten (A-J) Medigap policies offer a basic benefit package that includes coverage for Medicare Part A and Medicare Part B coinsurance.

Each insurance company selling Medigap must sell all the different Medigap policies.

Medicare SELECT is a Medicare supplement that uses a preferred provider organization (PPO) to supplement Medicare Part A coverage.

Medigap benefits vary by plan type (A through L), and are not uniform nationally.

ensure that Dr. Buhner complies with all of the provisions of the Ethics in Patient Referrals Act

learn whether Dr. Buhner is a licensed medical practitioner

confirm Dr. Buhner's membership in the National Committee for Quality Assurance (NCQA)

learn whether Dr. Buhner has had a medical malpractice claim filed or other disciplinary actions taken against her

health plans have more contracting options if providers are affiliated with single entities than if providers are affiliated with multiple entities

urban areas offer more flexibility in provider contracting than do rural areas

consumers and purchasers in markets with little health plan activity are likely to be more receptive to HMOs than to loosely managed plans such as PPOs

large employers tend to adopt health plans more slowly than do small companies

UCR fee

Capitation fee

Balance bill

Discounted fee-for-service

both Mr. Lee and Mr. Beeker

Mr. Lee only

Mr. Beeker only

neither Mr. Lee nor Mr. Beeker

EDI differs from eCommerce in that EDI involves back-and-forth exchanges of information concerning individual transactions, whereas eCommerce is the transfer of d

Both A and B

A only

B only

Neither A nor B

Advertising, personal selling, sales promotion, and publicity.

Advertising, price, sales promotion, and publicity.

Admissions, personal selling, sales promotion, and publicity.

Advertising, personal selling, sales promotion, and privacy.

Immunizations for children and adults

Tests and diagnostic procedures ordered with routine examinations

Smoking cessation programs

Gastric bypass surgery for obesity

expert consultation to end-users for solving specialized and complex healthcare problems through the use of a knowledge-based computer system

a comprehensive accreditation for PPOs

measurements of plan performance and effectiveness that potential healthcare purchasers can use to compare quality offered by different healthcare plans

a mathematical model that can predict future claim payments and premiums

Cost per procedure

Concurrent review

Cost of review

Access requirements

Only employers are permitted to establish and fund HRAs.

The popularity of HRAs waned following a 2002 ruling by U.S. Treasury Department regarding their treatment in the tax code.

HRAs must be offered in conjunction with a high-deductible health plan.

The guaranteed portability feature of HRAs has contributed to their popularity.

In the large group market, large group accounts that have employees in more than one geographic area who are covered through a single national contract for healthcare coverage are known as large local groups.

Because providing healthcare coverage for employees is often a burden for small businesses, price is typically the most critical consideration for small businesses in selecting a healthcare plan.

health plans typically treat an employer purchasing coalition as a small group for marketing purposes.

Large groups rarely use self-funding to finance their healthcare plans.

Deductible

Copayment

Capitation

Co-insurance

mandated certain requirements that all HMOs had to meet in order to conduct business

required that all HMOs be licensed as insurance companies

offered HMOs federal financial assistance through grants and loans, and provided access to the employer-based insurance market

encouraged the use of pre-existing condition exclusion provisions in all HMO contracts

Keith shall be entitled to Part A benefits when he attains 65 years of age

Keith’s wife shall be entitled to Part A benefits when she attains 65 years of age

Keith’s wife shall be required to pay a monthly premium in order to receive Medicare Part A benefits

Both a & b

a manual rating contract

a funding vehicle contract

an administrative services only (ASO) contract

a pooling contract

an amount based on the weighted value of each medical procedure or service that Isle provides, and the weighted value is determined by the appropriate current procedural terminology (CPT) code for the procedure or service

a fixed rate based on average expected use of hospital resources in a given geographical area for that DRG

a retrospective reimbursement based on the actual costs of the Oriole member's hospitalization

a specific negotiated amount for each day the Oriole member is hospitalized

staff model HMO

IPA model HMO

direct contract model HMO

network model HMO

operational / an acquisition

operational / a consolidation

structural / an acquisition

structural / a consolidation

A, B, C, and D

A, B, and D only

B, C, and D only

A and C only

both ethics and laws, and both ethics and laws are enforceable in the court system

both ethics and laws, but only laws are enforceable in the court system

ethics only, but only laws are enforceable in the court system

laws only, but both ethics and laws are enforceable in the court system

an integrated delivery system (IDS)

a Management Services Organization (MSO)

a Physician Practice Management (PPM) company

a physician-hospital organization (PHO)

Dr. High serves as the coordinator of care for the medical services that Mr. Canton receives.

Omega's network of providers includes Dr. High, but not Dr. Miller.

Omega's system allows its members open access to all of Omega's participating providers.

Omega used a financing arrangement known as a relative value scale (RVS) to compensate Dr. Miller.

fee-for-service arrangement

risk sharing contract

capitation contract

rebate contract

True

False

Has ever participated in any quality improvement activities.

Is a participating provider in a health plan that will compete with Ark in its new service area.

Meets the requirements of the Ethics in Patient Referrals Act.

Has had a medical malpractice claim filed or other disciplinary actions taken against her.

Coordinating and monitoring the member's care

Approve

Both A and B

A only

B only

Neither A nor B

a listing of drugs classified by therapeutic category or disease class that are considered preferred therapy for a given managed population and that are to be used by a health plan's providers in prescribing medications

a reduction in the price of a particular pharmaceutical obtained by the PBM from the pharmaceutical manufacturer

drugs ordered and delivered through the mail to the PBM's plan members at a reduced cost

an identification card issued by the PBM to its plan members