NEW QUESTION 1
Most health plans require a PCP referral or precertification for CAM benefits.

• A. True
• B. False

Answer: B

NEW QUESTION 2
The paragraph below contains two pairs of terms in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Health plans use both internal and external standards to assess the quality of the services that they provide. (Internal / External) standards are based on information such as published industry-wide averages or best practices of recognized industry leaders. Health plans primarily rely on (internal / external) standards to evaluate healthcare services.

• A. Internal / internal
• B. Internal / external
• C. External / internal
• D. External / external

Answer: D

NEW QUESTION 3
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 4
Determine whether the following statement is true or false:
The delegation of medical management functions to providers can occur without the transfer of financial risk.

• A. True
• B. False

Answer: A

NEW QUESTION 5
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

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

Answer: A

NEW QUESTION 6
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 7
CMS has developed two prototype programs—Programs of All-inclusive Care for the Elderly (PACE) and the Social Health Maintenance Organization (SHMO) demonstration project—to deliver healthcare services to Medicare beneficiaries. From the answer choices below, select the response that correctly identifies the features of these programs.

• A. PACE-annual limits on benefits for nursing home and community-based care SHMO-no limits on long-term care benefits
• B. PACE-provide long-term care only SHMO-provide acute and long-term care
• C. PACE-enrollees must be age 65 or older SHMO-enrollees must be age 55 or older
• D. PACE-enrollment open to nursing home certifiable Medicare beneficiaries only SHMO- enrollment open to all Medicare beneficiaries

Answer: D

NEW QUESTION 8
With respect to the activities of MCO medical directors, it is correct to say that medical directors typically perform all of the following activities EXCEPT

• A. maintaining clinical practices
• B. delivering performance feedback to providers
• C. participating in utilization management (UM) activities
• D. educating other MCO staff about new clinical developments or provider innovations that might impact clinical practice management

Answer: A

NEW QUESTION 9
Health plans conduct evaluations on the efficiency and effectiveness of their quality improvement activities. With regard to the effectiveness of quality improvement plans, it is correct to say that

• A. effectiveness is the relationship between what the organization puts into an improvement plan and what it gets out of the plan
• B. effectiveness is measured by reviewing outcomes to determine the accuracy or appropriateness of the strategy and the adequacy of resources allocated to that strategy
• C. the effectiveness of an action plan is typically measured with a concurrent evaluation
• D. an evaluation of plan effectiveness produces one of two results: the plan either (a) achieved the desired outcomes or (b) did not achieve the desired outcomes and is unlikely to do so under current conditions

Answer: B

NEW QUESTION 10
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

Answer: A

NEW QUESTION 11
DUR can be conducted prospectively, concurrently, or retrospectively. One true statement about prospective DUR is that it

• A. involves periodic audits of the medical records of a certain group of patients
• B. is based on historical data
• C. focuses on the drug therapy for a single patient rather than overall usage patterns
• D. is conducted by physicians, without input from pharmacists

Answer: C

NEW QUESTION 12
The following statements are about the use of provider profiling for pharmacy benefits. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. Health plans typically use provider profiles to improve the quality of care associated with the use of prescription drugs.
• B. Provider profiles identify prescribing patterns that fall outside normal ranges.
• C. Health plans can motivate providers to change their prescribing patterns by sharing profile information with plan members and the general public.
• D. Provider profiles are effective in modifying individual prescribing patterns, but they have little effect on group prescribing patterns.

Answer: D

NEW QUESTION 13
Accreditation is intended to help purchasers and consumers make decisions about healthcare coverage.
The following statements are about accreditation. Select the answer choice containing the correct statement.

• A. At the request of health plans, accrediting agencies gather the data needed for accreditation.
• B. Most purchasers and consumers review accreditation results when making decisions to purchase or enroll in a specific health plan.
• C. Accreditation is typically conducted by independent, not-for-profit organizations.
• D. All health plans are required to participate in the accreditation process.

Answer: C

NEW QUESTION 14
Since its inception, Medicare has undergone a number of changes because of legal and regulatory action. One result of the Balanced Budget Act (BBA) of 1997 has been to

• A. expand Medicare benefits by mandating coverage for certain preventive services
• B. reduce the number of organizations that can deliver covered services
• C. encourage growth of managed Medicare programs in all markets
• D. increase the number of “zero premium” plans available to Medicare beneficiaries

Answer: A

NEW QUESTION 15
The Midwest Health Plan delegated utilization review (UR) activities to the Tri-City Utilization Review Organization. After Tri-City improperly recommended denial of payment for services to a Midwest plan member, the plan member filed suit. The court ruled that Midwest was responsible for Tri-City’s actions because of the relationship between Midwest and Tri-City. This situation is an illustration of a legal concept known as

• A. vicarious liability
• B. fraud
• C. a tying arrangement
• D. subdelegation

Answer: A

NEW QUESTION 16
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