NEW QUESTION 1
Patricia McLeod is a member of the Enterprise Health Plan, which operates in State X. Ms. McLeod is scheduled to undergo a unilateral mastectomy for the treatment of breast cancer. The surgical procedure will be performed by Dr. Kim Lee, a surgical oncologist.
Based on Enterprise’s medical policy, the contract with the purchaser, and Ms. McLeod’s medical condition, Enterprise’s UR staff have determined that the appropriate course of care for Ms.
McLeod includes a 24-hour stay in the hospital following her surgery. State X, however, has a benefit mandate specifying health plan coverage for 48 hours of inpatient post- mastectomy care. In this situation, the length of hospital stay for which Enterprise must offer coverage is

• A. the length of stay deemed appropriate by D
• B. Lee
• C. the 24-hour stay determined to be appropriate by Enterprise’s UR staff
• D. the length of stay deemed appropriate by M
• E. McLeod
• F. the 48-hour length of stay specified by State X

Answer: D

NEW QUESTION 2
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 3
The following statement(s) can correctly be made about the characteristics of peer review:
* 1.Peer review is applicable to either single episodes of care or to entire programs of care
* 2.Most peer review is conducted concurrently
* 3.Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services furnished to Medicare and Medicaid recipients enrolled in health plans

• A. All of the above
• B. 1 and 2 only
• C. 1 and 3 only
• D. 2 and 3 only

Answer: C

NEW QUESTION 4
The Hall Health Plan gathered objective clinical information about the recommended uses and dosages of angiotensin-converting enzyme (ACE) inhibitors and presented the information to network providers to illustrate the appropriate use of these frequently prescribed and expensive drugs. This information indicates that Hall most likely educated its network providers through the use of

• A. detailing
• B. cognitive services
• C. counter detailing
• D. drug efficacy study implementation (DESI)

Answer: C

NEW QUESTION 5
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 6
Occasionally, employers combine workers’ compensation, group healthcare, and disability programs into an integrated product known as 24-hour coverage. One true statement about 24-hour coverage is that it typically

• A. increases administrative costs
• B. requires plans to maintain separate databases of patient care information
• C. exempts plans from complying with state workers’ compensation regulations
• D. allows plans to apply disability management and return-to-work techniques to nonoccupational conditions

Answer: D

NEW QUESTION 7
The nature of behavioral healthcare creates unique medical management challenges for health plans. One method health plans have used to support the delivery of appropriate services in a cost-effective manner is to

• A. remove behavioral healthcare services from the primary care setting
• B. shift behavioral healthcare from acute inpatient settings to alternative settings when feasible
• C. reserve the use of psychotherapy for treatment of those conditions that persist over long periods of time or for the life of the patient
• D. offer the same level of compensation to all of the professional disciplines that provide behavioral healthcare services to plan members

Answer: B

NEW QUESTION 8
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

Answer: C

NEW QUESTION 9
Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located at a military installation. Ms. Wilson serves as a primary point of contact between enrollees and the TRICARE system and answers enrollees’ questions about plan options, eligibility, provider selection, and claims. This information indicates that Ms. Wilson serves as a

• A. lead agent
• B. beneficiary services representative
• C. health plan support contractor
• D. primary care manager (PCM)

Answer: B

NEW QUESTION 10
When analyzing and applying HRA results, the Multistate Health Plan noted sampling bias. This information indicates that the HRA results

• A. do not accurately depict the characteristics of the Multistate member population under study because of errors in data collection
• B. are more accurate for individual Multistate members than they are for the total population
• C. cannot be stated in numerical terms
• D. indicate variation in the number, types, and severity of behavioral risks presented by Multistate’s members

Answer: A

NEW QUESTION 11
This agency has authority over Programs of All-inclusive Care for the Elderly (PACE) and the State Children’s Health Insurance Program (SCHIP).

• 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)

Answer: C

NEW QUESTION 12
Vision care is typically separated into two categories: routine eye care and clinical eye care. The standard benefit plans offered by most health plans include coverage for
* 1. Routine eye care
* 2. Clinical eye care

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

Answer: C

NEW QUESTION 13
Medicare beneficiaries can obtain healthcare benefits through fee-for-service (FFS) Medicare programs, Medicare medical savings account (MSA) plans, Medigap insurance, or coordinated care plans (CCPs). Unlike other coverage options, CCPs

• A. provide only those benefits covered by Medicare Part A and Part B
• B. are not subject to federal or state regulation
• C. place primary care at the center of the delivery system
• D. are structured as indemnity plans

Answer: C

NEW QUESTION 14
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

Answer: D

NEW QUESTION 15
To see that utilization guidelines are consistently applied, UR programs rely on authorization systems. Determine whether the following statement about authorization systems is true or false:
Only physicians can make nonauthorization decisions based on medical necessity.

• A. True
• B. False

Answer: A

NEW QUESTION 16
Determine whether the following statement is true or false:
The key to successfully managing the quality and cost-effectiveness of healthcare services for Medicaid enrollees is to merge Medicaid recipients into existing plans.

• A. True
• B. False

Answer: B

NEW QUESTION 17
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.

• A. Unbundling
• B. Outsourcing
• C. Data mining
• D. Drilling down

Answer: C

NEW QUESTION 18
The following statements are about health plans' complaint resolution procedures (CRPs). Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. An health plan's CRPs reduce the likelihood of errors in decision making.
• B. CRPs typically provide for at least two levels of appeal for formal appeals.
• C. CRPs include only formal appeals and do not apply to informal complaints.
• D. Most complaints are resolved without proceeding through the entire CRP process.

Answer: C

NEW QUESTION 19
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