AHM 540 - Tests

Assignment 1: The Medical Management Function
Reading 1A: The Role of Medical Management in a health plan
• Define the term medical management and explain the goals of this function
• Describe some common components of medical management programs
• Describe the role of the medical director in a health plan
• Explain the purpose of medical management committees and identify several common types of
medical management committees
• Define the terms delegation and subdelegation
• Explain why health plans sometimes delegate medical management activities
Instructions:
1. Select or enter the best answer for each of the 7 questions.

2. Answer all the questions. Remember to scroll down if
necessary.
3. Click Complete the Test to score your answers and view a Complete the Test
report.
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1. By definition, the development and implementation of parameters for the
question
delivery of healthcare services to a health plan’s members is known as
2.
utilization management (UM)
quality management (QM)
care management
clinical practice management
2. Determine whether the following statement is true or false:

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With respect to the size of a managed care organization (MCO) and its
question
medical management operations, it is correct to say that large health plans
3.
typically have more integration among activities and less specialization of
roles than do small MCOs.
True
False
3. With respect to the activities of MCO medical directors, it is correct to Go to

say that medical directors typically perform all of the following activities question
EXCEPT 4.
maintaining clinical practices
delivering performance feedback to providers
participating in utilization management (UM) activities
educating other MCO staff about new clinical developments or provider
innovations that might impact clinical practice management
4. The paragraph below contains two pairs of terms enclosed in
parentheses. Select the term in each pair that correctly completes the
paragraph. Then select the answer choice containing the two terms that
you have chosen. Go to
question
Under a delegation arrangement, the (delegate / delegator) is responsible 5.
for performing the delegated function according to established standards,
and the (delegate / delegator) is ultimately accountable for any deficiencies
in the performance of the function.
delegate / delegate
delegate / delegator
delegator / delegate
delegator / delegator

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question
The delegation of medical management functions to providers can occur
6.
without the transfer of financial risk.
True
False
6. For this question, if answer choices (1) through (3) are all correct, select
answer choice (4). Otherwise, select the one correct answer choice.
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question
Health plans sometimes delegate selected medical management activities
7.
to their providers or other external entities. Activities that are frequently
delegated include
utilization review (UR)
quality management (QM)
preventive health services
all of the above
7. MCOs usually have a formal program for the oversight of delegated

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activities. The following statements concern typical delegation oversight
Top
programs. Select the answer choice containing the correct statement.
A letter of intent is the contractual document that describes the
delegated functions and the responsibilities of the MCO and the
delegate.
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.
Under most delegation agreements, an MCO cannot terminate the
agreement before the end date stated in the agreement.
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.
>---------- End of the Test ----------<

1 D
2 B
3 A
4 B
5 A
6 A
7 D
Reading 1B: The Relationship of Medical Management to Other Health Plan Functions
• Explain the relationship between medical management and each of the following health plan
departments:
• Network management
• Risk management
• Legal affairs
• Claims administration
• Finance
• Sales and marketing
• Understand the role of information management in medical management operations and reporting
• Describe some of the technologies that health plans use to manage information
Instructions:

2. Answer all the questions. Remember to scroll down if necessary.
Complete the Test

3. Click Complete the Test to score your answers and view a report.
1. The Riverside Health Plan is considering the following provider
compensation options to use in its contracts with several provider groups and
hospitals:
1. A discounted fee-for-service (DFFS) payment system Go to
2. A case rate system question
3. Capitation 2.
If Riverside wants to use only those compensation methods that encourage
the efficient use of resources, then the compensation method(s) that
Riverside should consider for its new contracts include
1, 2, and 3
1 and 2 only
2 and 3 only
3 only
2. To facilitate electronic commerce (eCommerce), a health plan may Go to

establish a secured extranet. One true statement about a secured extranet is question
that it is 3.
based on Web-based technologies

available only to the employees of the health plan
publicly available, so the potential exists for unauthorized access to a
health plan’s proprietary systems
used to handle the majority of health plan eCommerce
3. The following statements are about health plans’ use of electronic data Go to
question
interchange (EDI). Three of the statements are true and one is false. Select
the answer choice containing the FALSE ALSE statement. 4.
One advantage of EDI over manual data management systems is
improved data integrity.
EDI may use the Internet as the communication link between the
participating parties.
EDI involves back-and-forth exchanges of information concerning
individual transactions.
The data format for EDI is agreed upon by the sending and receiving
parties.
4. For this question, if answer choices (A) through (C) are all correct, select
answer choice (D). Otherwise, select the one correct answer choice.
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question
Many health plans use data warehouses to assist with the performance of 5.
medical management activities. With respect to the characteristics of data
warehouses, it is generally correct to say
that the construction of a data warehouse is quick and simple
that a data warehouse addresses the problems associated with multiple
data management systems
that a data warehouse stores only current data
all of the above
5. The paragraph below contains an incomplete statement. Select the answer

choice containing the term that correctly completes the paragraph.
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question
Medical management programs often require the analysis of many types of 6.
data and information. __________________ is an automated process that
analyzes variables to help detect patterns and relationships in the data.
Unbundling
Outsourcing
Data mining
Drilling down
6. One method of transferring the information in electronic medical records

(EMRs) is through a health information network (HIN). The following Back to
statements are about HINs. Three of the statements are true and one is false. Top
Select the answer choice containing the FALSE statement.
A HIN may afford a health plan better measurements of outcomes and
provider performance.
The use of a HIN typically increases a health plan’s exposure to liability
for poor care.
Most HINs are Internet-based rather than built on proprietary computer
networks.
Currently, the majority of health plans do not have HINs that are
capable of transferring medical records among their network providers.
>---------- End of the Test ----------<
1 C
2 A
3 C
4 B
5 C
6 B
Reading 1C: Environmental Influences on Medical Management
• Describe the types of environmental factors that affect medical management programs of health
plans
• Discuss the expectations of purchasers, providers, and plan members for medical management
• Describe the major federal and state regulatory requirements that affect medical management
• Describe how environmental factors influence a health plan's delegation of medical management
functions
• Identify the main accrediting agencies and explain the impact of accreditation on medical
management
Instructions:

Complete the Test

1. Private employers are key purchasers of health plan services. The
following statement(s) can correctly be made about employer expectations
about the quality and cost-effectiveness of healthcare services:
1. For both health maintenance organizations (HMOs) and non-HMO

plans, employers typically have access to accreditation results and Go to
performance measurement reports to help them evaluate the quality question
of healthcare and service 2.
2. Because of employers’ concern about the quality and costs of

healthcare services available through health plans, direct contracting
has become a dominant model among employers who sponsor health
benefit programs for their employees
Both 1 and 2
1 only
2 only
Neither 1 nor 2
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2. State governments serve as both regulators and purchasers of health plan
question
services. The influence of state governments as purchasers is focused on 3.
Medicare and TRICARE programs

Medicaid and workers’ compensation programs
Medicare and Medicaid programs
TRICARE and workers’ compensation programs
3. Federal laws, such as the Employee Retirement Income Security Act
(ERISA), the Balanced Budget Act (BBA) of 1997, and the Health Insurance
Portability and Accountability Act (HIPAA), have affected medical
management activities by health plans. Consider the following provisions of
federal regulations:
• Provision 1—Limits damage awards in lawsuits related to

noncoverage of benefits based on medical necessity decisions to the Go to
cost of noncovered treatment and does not allow health plan members question
to obtain compensatory or punitive damages 4.
• Provision 2—Establishes electronic data security standards, which

define the security measures that healthcare organizations must take
to protect the confidentiality of electronically stored and transmitted
patient information From the answer choices below, select the
response that correctly identifies the federal laws that include
Provision 1 and Provision 2, respectively.
Provision 1- ERISA Provision 2- HIPAA
Provision 1- HIPAA Provision 2- ERISA
Provision 1- BBA of 1997 Provision 2- HIPAA
Provision 1- ERISA Provision 2- BBA of 1997
4. The Quality Assessment Performance Improvement (QAPI) is a quality

initiative designed to strengthen health plans’ efforts to protect and improve Go to
the health and satisfaction of Medicare and Medicaid health plan enrollees. question
The Centers for Medicare and Medicaid Services (CMS) requires compliance 5.
with QAPI from
both Medicare+Choice plans and Medicaid health plans
Medicare+Choice plans only
Medicaid health plans only
neither Medicare+Choice plans nor Medicaid health plans
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5. This agency has authority over Programs of All-inclusive Care for the
question
Elderly (PACE) and the State Children’s Health Insurance Program (SCHIP). 6.
Health Resources and Services Administration (HRSA)

Office of Personnel Management (OPM)
Department of Health and Human Services (HHS)
Department of Justice (DOJ)
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6. This agency oversees the Federal Employee Health Benefits Program
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(FEHBP). 7.

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7. This agency oversees fraud and abuse matters as they relate to medical
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management. 8.

8. The Midwest Health Plan delegated utilization review (UR) activities to the
Tri-City Utilization Review Organization. After Tri-City improperly
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recommended denial of payment for services to a Midwest plan member, the
question
plan member filed suit. The court ruled that Midwest was responsible for Tri- 9.
City’s actions because of the relationship between Midwest and Tri-City. This
situation is an illustration of a legal concept known as
vicarious liability
fraud
a tying arrangement
subdelegation
9. Accreditation is intended to help purchasers and consumers make

decisions about healthcare coverage. Go to
question
10.
The following statements are about accreditation. Select the answer choice
containing the correct statement.
At the request of health plans, accrediting agencies gather the data
needed for accreditation.
Most purchasers and consumers review accreditation results when
making decisions to purchase or enroll in a specific health plan.
Accreditation is typically conducted by independent, not-for-profit
organizations.
All health plans are required to participate in the accreditation process.
10. The following statement(s) can correctly be made about accrediting Go to

question
agency standards for delegation:
11.
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
Both 1 and 2
1 only
2 only
Neither 1 nor 2
11. Various government and independent agencies have created tools to

measure and report the quality of healthcare. One performance measurement Back to
tool that was developed by the Agency for Healthcare Research and Quality Top
(AHRQ) is
the Health Plan Employer Data and Information Set (HEDIS®), which is
a report card system for hospitals and long-term care facilities
HEDIS, which is a performance measurement tool that addresses both
effectiveness of care and plan member satisfaction
the Consumer Assessment of Health Plans (CAHPS®), which was
established to develop and implement a national strategy for quality
measurement and reporting
CAHPS, which is a tool that measures consumer satisfaction with specific
aspects of health plan services
>---------- End of the Test ----------<
1 D
2 B
3 A
4 B
5 C
6 B
7 D
8 A
9 C
10 C
11 D
Assignment 2: Clinical Practice Management
Reading 2A: Clinical Practice Management
• Describe the components of a health plan's coverage policy

• List several types of services that health plans typically limit or exclude
• Describe the types of coverage issues typically addressed by medical policy
• Explain the importance of technology assessment as it relates to medical policy
• Explain the role of clinical practice guidelines
Instructions:

Complete the Test

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To manage the delivery of healthcare services to their members, health plans question
2.
use clinical practice parameters. ___________________ is the type of clinical
practice parameter that a health plan uses to make coverage decisions
concerning medical necessity and appropriateness.
A clinical practice guideline (CPG)
Medical policy
Benefits administration policy
A standard of care
2. Three general categories of coverage policy—medical policy, benefits

administration policy, and administrative policy—are used in conjunction with Go to
purchaser contracts to determine a health plan’s coverage of healthcare question
services and supplies. With respect to the characteristics of the three types of 3.
coverage policy, it is correct to say that a health plan’s
medical policy evaluates clinical services against specific benefits
language rather than against scientific evidence
benefits administration policy determines whether a particular service is
experimental or investigational
benefits administration policy focuses on both clinical and nonclinical
coverage issues
administrative policy contains the guidelines to be followed when
handling member and provider complaints and disputes
3. A health plan’s coverage policies are linked to its purchaser contracts. The Go to
question
following statement(s) can correctly be made about the purchaser contract
4.
and coverage decisions:
1. In case of conflict between the purchaser contract and a health plan’s

medical policy or benefits administration policy, the contract takes
precedence
2. Purchaser contracts commonly exclude custodial care from their
coverage of services and supplies
3. All of the criteria for coverage decisions must be included in the

purchaser contract
All of the above
1 and 2 only
2 only
3 only
4. Helena Ray, a member of the Harbrace Health Plan, suffers from migraine
headaches. To treat Ms. Ray’s condition, her physician has prescribed Upzil, a
medication that has Food and Drug Administration (FDA) approval only for
the treatment of depression. Upzil has not been tested for safety or
effectiveness in the treatment of migraine headache. Although Harbrace’s Go to
medical policy for migraine headache does not include coverage of Upzil, question
Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. 5.
Ray.
In this situation, the prescribing of Upzil for Ms. Ray’s headaches is an

example of
a cosmetic service
an investigational service
an off-label use
a quality-of-life service
5. Helena Ray, a member of the Harbrace Health Plan, suffers from migraine
headaches. To treat Ms. Ray’s condition, her physician has prescribed Upzil, a
medication that has Food and Drug Administration (FDA) approval only for
the treatment of depression. Upzil has not been tested for safety or
effectiveness in the treatment of migraine headache. Although Harbrace’s
medical policy for migraine headache does not include coverage of Upzil,
Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms.
Ray.
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question
The following statement(s) can correctly be made about Harbrace’s use of 6.
extra-contractual coverage:
1. Harbrace’s medical policy most likely establishes the procedure that

Harbrace used to evaluate the value of Upzil for treating Ms. Ray
2. One way for Harbrace to reduce the risk associated with extra-
contractual coverage is by including an alternative care provision in its
contracts with purchasers
Both 1 and 2
1 only
2 only
Neither 1 nor 2
6. The following statements are about health plans’ development of medical Go to

policies. Three of the statements are true and one is false. Select the answer question
choice containing the FALSE statement. 7.
Technology assessment is applicable only to medical policy development

for new medical procedures, devices, drugs, and tests.
Technology assessment provides the scientific rationale for the medical
policy section that specifies when a medical service is appropriate and
when it is not.
The medical policy development process includes both a clinical and an
operational review of a proposed medical policy.
The decision to accept or reject a proposed medical policy often depends
on how a new technology compares to currently used interventions.
7. For this question, if answer choices (a) through (c) are all correct, select
answer choice (d). Otherwise, select the one correct answer choice.
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Top
Well-crafted clinical practice guidelines (CPGs) can benefit healthcare delivery
processes and outcomes by
providing a framework for care while also allowing for patient-specific
variations, based on physician judgment
serving as a basis for evaluating whether providers are practicing in
accordance with accepted standards
focusing on the prevention or early detection of a particular condition
all of the above
>---------- End of the Test ----------<

1 B
2 D
3 B
4 C
5 C
6 A
7 D
Assignment 3: Quality Management in health plan
Reading 3A: Quality Management
• Describe the major steps in the quality management process

• Describe the role of outcomes in quality management
• Identify the characteristics, uses, and sources of quality standards
• Describe the differences between traditional healthcare and population-based healthcare
• Describe how quality management relates to risk management and information management
Instructions:

Complete the Test

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Definitions of quality healthcare vary; however, four dimensions are essential question
2.
to quality healthcare services. ________________ is the quality dimension
indicating that services result in the best care for a given cost or the lowest
cost for a given level of care.
Accessibility
Effectiveness
Acceptability
Efficiency
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2. One difference between outcomes research and clinical research is that
question
outcomes research 3.
provides an absolute measure of treatment results, whereas clinical
research provides a relative measure of results
focuses on treatment effectiveness, whereas clinical research focuses on
treatment efficacy
examines diseases and treatments in isolation, whereas clinical research
considers the effects of changes in health status and quality of life
gathers outcomes data from controlled clinical trials, whereas clinical
research collects and analyzes clinical, financial, and administrative data
3. Outcomes management is a tool that health plans use to maximize all the Go to
question
results associated with healthcare processes. The following statement(s) can
4.
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
Both 1 and 2
1 only
2 only
Neither 1 nor 2
4. 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.
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Health plans use both internal and external standards to assess the quality of question
5.
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.
Internal / internal
Internal / external
External / internal
External / external

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All health plans participating in the Federal Employee Health Benefits question
6.
Program (FEHBP) are required to use the Consumer Assessment of Health
Plans (CAHPS) to measure customer satisfaction.
True
False
6. This agency’s accreditation decisions are based on the results of an on-site

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survey of clinical and administrative systems and processes, as well as the
question
health plan’s performance on selected effectiveness of care and member 7.
satisfaction measures.
American Accreditation HealthCare Commission/URAC (URAC)
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Community Health Accreditation Program (CHAP)
National Committee for Quality Assurance (NCQA)
7. Among this agency’s accreditation programs are accreditation for preferred

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provider organizations (PPOs), health plan call centers, and case
question
management organizations. This agency classifies its standards as either 8.
“shall” standards or “should” standards.
Community Health Accreditation Program (CHAP)
8. Patient safety and medical errors are important concerns for both quality
management (QM) and risk management. The following statement(s) can
correctly be made about medical errors:
1. The complexity of modern medicine and healthcare delivery systems

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increases patients’ exposure to the risks of medical errors Top
2. Licensing boards for healthcare professionals in all states provide a
consistent system of quality oversight and accountability
3. Provider compliance with internal incident reporting requirements is

low
All of the above
1 and 2 only
1 and 3 only
3 only
>---------- End of the Test ----------<
1 D
2 B
3 A
4 D
5 A
6 D
7 A
8 C
Reading 3B: Quality Assessment
• Describe the major components of a quality assessment program

• Describe the methods health plans use to identify and prioritize key services and processes
• Identify the types of standards and indicators used in performance measurement
• Identify the three main types of performance measures and describe their advantages and disadvantages
• Explain the importance of case mix/severity adjustment
• Describe the types and sources of data needed to measure performance
• Describe the use of plan and provider report cards
• Identify some of the major issues and barriers in performance measurements
Instructions:

Complete the Test

1. When conducting performance assessment, a health pln may classify the
key processes associated with its services into the following categories: high-
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risk, high-volume, problem-prone, and high-cost.
question
The following statements are about this classification of processes. Three of 2.
the statements are true and one is false. Select the answer choice containing
the FALSE statement.
In some instances, relatively inexpensive processes can qualify as high-
cost processes.
Each process must be classified into a single category.
High-risk processes most often involve medical interventions or
treatment plans for acute illnesses or case management processes for
complex conditions.
Administrative processes such as scheduling appointments are examples
of high-volume processes.
2. The Westchester Health Plan classifies its key processes into the following
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categories: high-risk, high-volume, problem-prone, and high-cost.
question
Westchester also prioritizes the categories in terms of importance. The 3.
process category that Westchester most likely ranks highest in importance is
high-risk processes
high-volume processes
problem-prone processes
high-cost processes
3. The paragraph below contains an incomplete statement. Select the answer Go to

question
4.
Each quality standard used by a health plan is associated with quality

indicators. A ______________ indicator is a form of aggregate data indicator
that produces results that fit within a specified range, such as the length of
time to schedule an appointment.
yes/no
sentinel event
discrete variable
continuous variable
4. In order to provide a true measure of quality, the data collected by a

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quality indicator should accurately represent the service dimension being
question
measured. This information indicates that the indicator should exhibit the 5.
characteristic known as
clarity
reliability
validity
feasibility
5. The following statement(s) can correctly be made about performance

measurement systems:
1. The most difficult purpose for a performance measurement system to

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address is to measure changes in outcomes caused by modifications in
question
administrative or clinical treatment processes 6.
2. A health plan needs different performance measurement systems to

evaluate its administrative services and the clinical performance of its
providers
Both 1 and 2
1 only
2 only
Neither 1 nor 2
6. Health plan performance measures include structure measures, process

measures, and outcome measures. The following statements are about the Go to
characteristics of these three types of performance measures. Three of the question
statements are true and one is false. Select the answer choice containing the 7.
FALSE statement.
The most widely used structure measures relate to physician education
and training.
One advantage of structure measures over process measures is that
structures are often linked directly to healthcare outcomes.
Process measures are useful in identifying underuse, overuse, and
inappropriate use of services.
One disadvantage of outcome measures is that they can be influenced
by factors outside the control of the health plan.
7. A health plan’s choice of structure measures, process measures, and

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outcome measures to evaluate performance depends in part on the scientific
question
soundness of the measures. One approach that a health plan can use to 8.
enhance scientific soundness is stratification, which refers to the
identification and removal of unusual cases, such as patients with
contraindications to a particular treatment, from consideration
statistical adjustment of outcome measures to account for differences in
the severity of illness or the presence of other medical conditions
specification of a target population for a procedure and the data
collection and analysis methods to be used
elimination of variation within a patient population by dividing the
population into groups that are at a similar level of risk
8. To measure performance for quality management, health plans collect and

analyze three types of data: financial data, clinical data, and customer
satisfaction data. The following statement(s) can correctly be made about the
sources of clinical data:
1. Patient surveys are the most widely used source of disease-specific Go to

clinical information question
2. Outcomes research studies sponsored by academic institutions and 9.
professional organizations have limited usefulness for particular health
plans or individual providers
3. The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys

address both physical and mental health status
All of the above
1 and 2 only
2 and 3 only
3 only
9. Increased demands for performance information have resulted in the

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development of various health plan report cards. With respect to most of the Top
report cards currently available, it is correct to say
that they are focused primarily on health maintenance organization
(HMO) plans
that they are based on data collected for the Health Plan Employer Data
and Information Set (HEDIS) 3.0
that they are used to rank the performance of various health plans
all of the above
>---------- End of the Test ----------<

1 B
2 A
3 D
4 C
5 C
6 B
7 D
8 C
9 D
Reading 3C: Quality Improvement
• Identify the major components of the performance improvement cycle

• Describe how health plans use benchmarking to guide quality improvement activities
• Identify the goals of member education and outreach programs
• Describe the techniques health plans use to improve providers' ability to work within the healthcare system
• Describe three tools health plans can use to support provider decision making and improve clinical performance
Instructions:

Complete the Test

1. In order to achieve changes in outcomes, health plans make changes to
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existing structures and processes. The introduction of preauthorization as an
question
attempt to control overuse of services is an example of a reactive change. 2.
Reactive changes are typically
both planned and controlled
planned, but they are rarely controlled
controlled, but they are rarely planned
neither planned nor controlled
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2. In order for a health plan’s performance-based quality improvement
question
programs to be effective, the desired outcomes must be 3.
achievable within a specified timeframe

defined in terms of multiple results
expressed in subjective, qualitative terms
all of the above
3. Health plans communicate proposed performance changes through action Go to

statements. Select the answer choice containing an action statement that question
includes all of the required elements. 4.
The proportion of adult members who are screened for hypertension will
increase by ten percent.
Primary care providers (PCPs) will increase the proportion of children
under the age of two who are up-to-date on immunizations by seven
percent within one year.
The QM program director will evaluate the level of provider compliance
with clinical practice guidelines (CPGs).
The disease management program director will increase participation by
asthmatic children in the health plan’s pediatric asthma disease
management program.
4. Administrative action plans are used when performance problems or
opportunities are related to the way the organization itself operates. The
following statement(s) can correctly be made about administrative action
plans:
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1. Administrative action plans allow health plans to coordinate
question
management activities 5.
2. One function of administrative action plans is to integrate service
across all levels of the organization
3. Administrative action plans are designed to improve outcomes by

helping plan members assume responsibility for their own health
All of the above
1 and 2 only
1 and 3 only
2 and 3 only
5. As a follow-up to a performance improvement plan for member services,

the Stellar Health Plan conducted an evaluation of the success of the plan.
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Stellar conducted its evaluation as the plan was being carried out. The
question
evaluation focused on specific activities and assessed the relative importance 6.
of those activities to the plan as a whole. This information indicates that
Stellar’s evaluation of the plan was both
concurrent and formative
concurrent and summative
retrospective and formative
retrospective and summative
6. Health plans conduct evaluations on the efficiency and effectiveness of Go to

their quality improvement activities. With regard to the effectiveness of question
quality improvement plans, it is correct to say that 7.
effectiveness is the relationship between what the organization puts into

an improvement plan and what it gets out of the plan
effectiveness is measured by reviewing outcomes to determine the
accuracy or appropriateness of the strategy and the adequacy of
resources allocated to that strategy
the effectiveness of an action plan is typically measured with a
concurrent evaluation
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
7. The paragraph below contains two pairs of terms or phrases enclosed in Go to

question
parentheses. Determine which term or phrase in each pair correctly
8.
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.
objective / degree
objective / cause
both objective and subjective / degree
both objective and subjective / cause
8. Performance variance can be classified as either common cause variance

or special cause variance. The following statement(s) can correctly be made
about special cause variance:
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1. Inadequate staffing levels, employee errors, and equipment question
malfunctions are examples of special cause variance 9.
2. Special cause variance is typically more difficult to detect and correct

than is common cause variance
Both 1 and 2
1 only
2 only
Neither 1 nor 2
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9. Benchmarking is a quality improvement strategy used by some health
question
plans. With regard to benchmarking, it is correct to say that 10.
cost-based benchmarking reveals why some areas of a health plan
perform better or worse than comparable areas of other organizations
diagnosis-related groups (DRGs) are a source of benchmarking data that
describe individual procedures and cover both inpatient and outpatient
care
patient billing records provide a much more accurate account of
procedure costs for benchmarking than do current procedural
terminology (CPT) codes
the focus of benchmarking for health plan has shifted from identifying
the lowest cost practices to identifying best practices
Go to
10. The Garnet Health Plan uses provider profiling to measure and improve
question
provider performance. Provider profiling most likely allows Garnet to 11.
evaluate all providers without considering differences in risk

focus on specific clinical decisions of Garnet’s providers rather than on
patterns of care
identify the outliers and high-value providers in its provider network
measure the effectiveness, but not the efficiency, of Garnet’s providers
11. 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 Back to
2. Most peer review is conducted concurrently Top
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
All of the above
1 and 2 only
1 and 3 only
2 and 3 only
>---------- End of the Test ----------<

1 C
2 A
3 B
4 B
5 A
6 B
7 A
8 B
9 D
10 C
11 C
Assignment 4: Preventive Care, Self-Care, and Decision Support Programs
Reading 4A: Preventive Care Programs
• Identify the three levels of preventive care

• Explain the role of health risk assessment (HRA) for preventive care
• Describe some strategies that health plans may use to enhance member participation in preventive care programs
Instructions:

Complete the Test

1. A health plan's preventive care initiatives may be classified into three main Go to
categories: primary prevention, secondary prevention, and tertiary question
prevention. Secondary prevention refers to activities designed to 2.
develop an appropriate treatment strategy for patients whose conditions

require extensive, complex healthcare
educate and motivate members to prevent illness through their lifestyle
choices
prevent the occurrence of illness or injury
detect a medical condition in its early stages and prevent or at least
delay disease progression and complications
2. Some health plans administer a questionnaire known as the Behavioral

Risk Factor Surveillance System (BRFSS) as part of their health risk Go to
assessment (HRA) processes. The following statements are about the BRFSS. question
If statements (A) through (C) are all correct, select answer choice (D). 3.
Otherwise, select the one correct statement.
This questionnaire was designed specifically for use by health plans.
Each health plan must use the same form of the questionnaire, with no
additions or modifications.
This questionnaire monitors the prevalence of the major behavioral risks
associated with illness and injury among adults.
All of the above statements are correct.
3. Many health plans use HRA to target their preventive care programs to the Go to
healthcare needs of their members. With regard to HRA, it is correct to say question
that 4.
Health plans rarely delegate HRA activities to external entities

Health plans typically focus their HRA efforts on newly enrolled members
HRA focuses on clinical data for an entire population and does not
include demographic information that might identify individual members
HRA is generally a reliable predictor of medical resource utilization
Go to
4. When analyzing and applying HRA results, the Multistate Health Plan noted
question
sampling bias. This information indicates that the HRA results 5.
do not accurately depict the characteristics of the Multistate member
population under study because of errors in data collection
are more accurate for individual Multistate members than they are for
the total population
cannot be stated in numerical terms
indicate variation in the number, types, and severity of behavioral risks
presented by Multistate’s members

Go to
question
Immunization programs are a direct means of reducing health plan members’ 6.
needs for healthcare services and are typically cost-effective.
True
False
Go to
6. Readiness is an important consideration for the development of health
question
promotion programs. Readiness refers to 7.
the availability of previously established health promotion programs to
an health plan’s members through employers, providers, or community
service agencies
the appropriateness of a program’s educational approach, given the
language, literacy level, and cultural sensitivities of the target population
a member’s level of knowledge about existing health risks and problems
and the member’s ability and willingness to adopt new health-related
behaviors
a member’s access to information technology, such as a video cassette
recorder, a computer, or the Internet
7. The following statement(s) can correctly be made about the use of

screening for secondary prevention:
1. Screening activities may involve specialty care providers as well as

primary care providers (PCPs) and the health plan Back to
2. Secondary prevention often results in more utilization of services Top
immediately following screening
3. Screening focuses on members who have not experienced any

symptoms of a particular illness
All of the above
1 and 3 only
2 and 3 only
1 only
>---------- End of the Test ----------<

1 D
2 C
3 B
4 A
5 A
6 C
7 A
Reading 4B: Self-Care and Decision Support Programs
• Describe the use of telephone triage services in self-care and decision support programs
• Identify general methods that health plans use to evaluate the effectiveness of preventive care, self-care, and
decision support programs
• Discuss the use of integration and partnerships to improve preventive care, self-care, and decision support programs
Instructions:

Complete the Test

1. The following statements describe situations in which health plan members Go to
have medical problems that require care. Select the statement that describes question
a situation in which self-care most likely would not be appropriate. 2.
Two days after bruising her leg, Avis Bennet notices that the pain from
the bruise has increased and that there are red streaks and swelling
around the bruised area.
Calvin Dodd has Type II diabetes and requires blood glucose monitoring
tests several times each day.
Caroline Evans has severe arthritis that requires regular exercise and
oral medication to reduce pain and help her maintain mobility.
Oscar Gracken is recovering from a heart attack and requires ongoing
cardiac rehabilitation.
2. To improve members’ abilities to make appropriate care decisions about

specific medical problems, some health plans use a form of decision support Go to
known as telephone triage programs. The following statements are about question
telephone triage programs. Select the answer choice containing the correct 3.
statement.
The primary role of telephone triage clinical staff is to diagnose the
caller’s condition and give medical advice.
Quality management (QM) for telephone triage programs typically
focuses on the clinical information provided rather than on the quality of
service.
Currently, none of the major accrediting agencies offers an accreditation
program specifically for telephone triage programs.
A telephone triage program may also include a self-care component.
3. Emilio Martinez, a member of the Bloom Health Plan, has recently been Back to
Top
diagnosed with prostate cancer by his physician, Dr. Robert Cohen. Mr.
Martinez has decided to participate in Bloom’s shared decision-making
program for prostate cancer. On the basis of this information, it is most likely
correct to say
1. That verification of Mr. Martinez’s understanding about his care

options protects both Dr. Cohen and Bloom against charges of
malpractice
2. That Mr. Martinez and Dr. Cohen will discuss the care options available
to Mr. Martinez, but the ultimate decision about care is up to Dr.
Cohen
Both 1 and 2
1 only
2 only
Neither 1 nor 2
>---------- End of the Test ----------<
1 A
2 D
3 B
Assignment 5: Utilization Review
Reading 5A: Utilization Review
• Discuss some of the key issues health plans must address to develop and maintain effective utilization review
programs
• Explain the importance of medical necessity, medical appropriateness, and utilization review process
• Describe the role of authorizations and member appeals in the utilization review process
• Identify some of the ways that health plans evaluate the results of utilization review programs
Instructions:

Complete the Test

1. The following statements are about the characteristics of a utilization Go to
review (UR) program. Three of the statements are true and one is false. question
Select the answer choice containing the FALSE statement. 2.
A primary goal of UR is to address practice variations through the

application of uniform standards and guidelines.
UR evaluates whether the services recommended by a member’s
provider are covered under the benefit plan.
UR recommends the procedures that providers should perform for plan
members.
A health plan’s UR program is usually subject to review and approval by
the state insurance and/or health departments.
2. The paragraph below contains two pairs of terms or phrases enclosed in

completes the paragraph. Then select the answer choice containing the terms
or phrases that you have chosen. Go to
question
3.
One component of UR is an administrative review. An administrative review
compares the proposed medical care to the applicable (medical policy /
contract provision). This type of review (can / cannot) be conducted by a
nonclinical staff member.
medical policy / can
medical policy / cannot
contract provision / can
contract provision / cannot
Go to
3. The Brighton Health Plan regularly performs prospective UR for surgical
question
procedures. Brighton’s prospective UR activities are likely to include 4.
documenting the clinical details of the patient’s condition and care

tracking the length of inpatient stay
completing the discharge planning process
determining the most appropriate setting for the proposed course of care
4. The following statement(s) can correctly be made about utilization

guidelines:
Go to
1. When developing utilization guidelines, health plans balance evidence-
question
based criteria with experience-based criteria 5.
2. Utilization guidelines indicate when a UR nurse should refer a decision

to a physician reviewer
Both 1 and 2
1 only
2 only
Neither 1 nor 2
5. 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: Go to
question
6.
Only physicians can make nonauthorization decisions based on medical
necessity.
True
False
6. The paragraph below contains two pairs of terms or phrases enclosed in

or phrases that you have chosen.
Go to
question
Due to competitive pressures and consumer demand, many health plans now 7.
offer direct access or open access products. Under a direct access product, a
member is (required / not required) to select a primary care provider (PCP),
and is (required / not required) to obtain a referral from a PCP or the health
plan before visiting a network specialist.
required / required
required / not required
not required / required
not required / not required
7. The following statements are about health plans' complaint resolution Go to

procedures (CRPs). Three of the statements are true and one is false. Select question
the answer choice containing the FALSE statement. 8.
An health plan's CRPs reduce the likelihood of errors in decision making.

CRPs typically provide for at least two levels of appeal for formal
appeals.
CRPs include only formal appeals and do not apply to informal
complaints.
Most complaints are resolved without proceeding through the entire CRP
process.
8. Helath plans have a specified number of working days to respond to Level

One appeals, as stated by company policy or regulatory requirements. With
regard to the timeframes for appeals, it is generally correct to say
Go to
1. That the typical timeframe requires a health plan to respond to question
appeals in fewer than 20 days 9.
2. That the timeframe is accelerated for expedited appeals
3. That the review period begins when the appeal arrives at a health plan
All of the above
1 and 2 only
1 and 3 only
2 and 3 only

Go to
Independent review organizations (IROs) can mediate disputes and offer question
10.
advisory opinions to health plans on UR issues, but they cannot render
binding decisions on appeals.
True
False
10. 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
Go to
medical policy, the contract with the purchaser, and Ms. McLeod’s medical
question
condition, Enterprise’s UR staff have determined that the appropriate course 11.
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
the length of stay deemed appropriate by Dr. Lee
the 24-hour stay determined to be appropriate by Enterprise’s UR staff
the length of stay deemed appropriate by Ms. McLeod
the 48-hour length of stay specified by State X
11. One way that health plans evaluate their UR programs is by monitoring Back to
Top
utilization rates. By definition, utilization rates typically
indicate changes in the total amount of medical expenses or claim
dollars paid for particular procedures
measure the number of services provided per 1,000 members per year
indicate standard approaches to care for many common, uncomplicated
healthcare services
report the number of times that a particular provider performs or
recommends a service excluded from the benefit plan
>---------- End of the Test ----------<
1 C
2 C
3 D
4 A
5 A
6 B
7 C
8 D
9 B
10 D
11 B
Assignment 6: Case Management
Reading 6A: Case Management
• Describe a variety of case management activities

• Explain the steps of the case management process
• Identify several strategic issues that may affect the development and improvement of case management programs
• Discuss the impact of legal issues, regulations, and accrediting agencies on case management functions
Instructions:

Complete the Test

answer choice (D). Otherwise, select the one correct answer choice. Go to
question
2.
In most commercial health plans, the case management process is directed
by a case manager whose responsibilities typically include
focusing on a disabled member’s vocational rehabilitation and training
approving all care decisions for patients under case management
reducing the fragmentation of care that often results when individuals
obtain services from several different providers
all of the above
2. The following statement(s) can correctly be made about the scope of case
management:
1. Case management incorporates activities that may fall outside a

health plan’s typical responsibilities, such as assessing a member’s
Go to
financial situation
question
2. Case management generally requires a less comprehensive and 3.
complex approach to a course of care than does utilization review
3. Case management is currently applicable only to medical conditions

that require inpatient hospital care and are categorized as catastrophic
in terms of health and/or costs
All of the above
1 and 2 only
2 and 3 only
1 only
3. Determine whether the following statement is true or false: Go to

question
4.
The utilization review (UR) process produces the greatest number of case
management referrals.
True
False
4. Breanna Osborn is a case manager for a regional health plan. One

Go to
component of Ms. Osborn’s job is the collection and evaluation of medical,
question
financial, social, and psychosocial information about a member’s situation. 5.
This component of Ms. Osborn’s job is known as
case identification
case management planning
healthcare coordination
case assessment
5. The following statements are about risk management for case Go to

management. Three of the statements are true and one is false. Select the question
answer choice containing the FALSE statement. 6.
The use of a signed consent authorization form is consistent with

accrediting agency standards for patient privacy and confidentiality of
medical information.
Case management that is initiated after a member has incurred
substantial medical expenses is more likely to be viewed as a tool to cut
costs rather than to improve outcomes.
Health plan documents indicating that any case management delegates
are separate, independent entities may reduce an health plan's exposure
to risk.
A case management file cannot be used to support the health plan's
position in the event of a lawsuit.
6. The case management program director at the Nova Health Plan calculated
the program’s ratio of medical expense savings to case management
administrative costs for the previous quarter based on the following cost
information:
Administrative costs for case management ..........$40,000 Go to
Actual medical care expenses for patients under case question
management ..........$680,000 7.
Projected medical care expenses for the same patients without case
management ..........$900,000
This information indicates that, for the previous quarter, Nova’s ratio of
medical expense savings to case management administrative costs was
0.71/1
0.80/1
5.50/1
1.25/1
Go to
7. One true statement about state regulation of case management activities
question
is that the majority of states 8.
have enacted laws that list specific quality management requirements for
a case management program
consider case management files to be medical records that must be
retained for a specified length of time
view case management similarly and follow similar patterns with their
laws and regulations
have enacted laws or regulations requiring licensure or certification of
case managers
8. The American Accreditation HealthCare Commission/URAC (URAC) has an

accreditation program specifically for case management services. From the
Back to
answer choices below, select the response that correctly identifies the type(s) Top
of case management services addressed by URAC’s standards and the type(s)
of organizations to which these standards may be applied.
Type(s) of Services-on-site services only Type(s) of Organization-
health plans only
Type(s) of Services-on-site services only Type(s) of Organization-
any organization that performs case management functions
Type(s) of Services-both telephonic and on-site services Type(s) of
Organization-health plans only
Type(s) of Services-both telephonic and on-site services Type(s) of
Organization-any organization that performs case management
functions
>---------- End of the Test ----------<
1 C
2 D
3 A
4 D
5 D
6 C
7 B
8 D
Assignment 7: Disease Management
Reading 7A: Disease Management
• Distinguish between disease management and case management

• Explain why health plans establish disease management programs
• Describe the types of organizations that provide disease management
• Explain the decisions a health plan must make to implement a disease management program
• Describe four approaches to integrating information disease management programs
Instructions:

Complete the Test

1. The following statements are about disease management programs. Three Go to
of the statements are true and one is false. Select the answer choice question
containing the FALSE statement. 2.
The focus of disease management is on responding to the needs of

individual members for extensive, customized healthcare supervision.
Disease management programs serve to improve both clinical and
financial outcomes for healthcare services related to chronic conditions.
Tools such as preventive care, self-care, and decision support programs
are used to support both case management and disease management.
Disease management programs apply to both diseases and medical
conditions that are not diseases, such as high-risk pregnancy, severe
burns, and trauma.

Go to
Under a carve-out arrangement for disease management, patients typically question
3.
maintain their existing relationships with primary care providers (PCPs) for all
care, including disease management.
True
False
3. Comorbidity can have a significant impact on the effective implementation Go to

of disease management programs. Comorbidity can correctly be defined as question
the 4.
degree to which the progression of a disease or condition is understood

prevalence or rate of a sickness or injury within a given population
degree of severity of a particular disease or condition
presence of a chronic condition or added complication other than the
condition that requires medical treatment
4. Selene Varga is participating in her health plan’s disease management
program for congestive heart failure. Ms. Varga’s health status is regularly
Go to
monitored and managed by a licensed nurse who visits Ms. Varga at her
question
home to administer treatment and assess the need for changes in Ms. 5.
Varga’s overall care plan. This information indicates that Ms. Varga is
participating in the type of disease management program known as a
coordinated outreach model program
case management model program
hub-and-spoke model program
group clinic model program
5. The Fairview Health Plan uses a dual database approach to integrate Go to

information needed for its disease management program. This information question
indicates that Fairview uses an information management system that 6.
combines all existing information from all data sources into a single
comprehensive system
connects multiple databases with a central interface engine that acts as
an information clearinghouse
provides an outside vendor with pertinent data that the vendor compiles
into an integrated database
creates a separate database that pulls pertinent information from the
health plan’s claims database, formats the information for easy analysis,
and stores it in the separate database
6. The Carlyle Health Plan uses the following clinical outcome measures to
evaluate its diabetes and asthma disease management programs:
Measure 1: The percentage of diabetic patients who receive foot
exams from their providers according to the program’s recommended Go to
guidelines Measure 2: The number of asthma patients who visited question
emergency departments for acute asthma attacks 7.
From the answer choices below, select the response that correctly identifies
whether these measures are true outcome measures or intermediate
outcome measures. Measure 1- Measure 2-
Measure 1-true outcome measure Measure 2-true outcome measure
Measure 1-true outcome measure Measure 2-intermediate outcome
measure
Measure 1-intermediate outcome measure Measure 2-true outcome
measure
Measure 1-intermediate outcome measure Measure 2-intermediate
outcome measure

Back to
Top
Participation in disease management programs is currently voluntary.
True
False
>---------- End of the Test ----------<
1 A
2 B
3 D
4 B
5 D
6 C
7 A
Assignment 8: Medical Management Considerations for Different Levels of Care
Reading 8A: Medical Management Strategies for Acute Care
• Describe the potential benefits and drawbacks of using hospitalists for the management of inpatient acute care
• Explain why the utilization of emergency services is an ongoing concern for health plans and describe some
approaches that health plans may use to improve utilization management for emergency care
• Explain how clinical pathways are useful medical management tools and how health plans facilitate development of
them
• Define the term center of excellence and describe how its use may benefit health plan medical management
programs
Instructions:

Complete the Test

Go to
1. Acute care refers to healthcare services for medical problems that question
2.
are expected to continue for a minimum of 30 days

are typically treated in a provider’s office or outpatient facility
require prompt, intensive treatment by healthcare providers
require low utilization of resources
Go to
2. The following statements are about the use of hospitalists to manage
question
inpatient care. Select the answer choice containing the correct statement. 3.
A patient who has been transferred to a hospitalist for management of
inpatient care usually continues to receive care from the hospitalist after
discharge.
Hospitalists are used primarily to manage care for obstetric, pediatric,
and oncology patients.
In order to serve as a hospitalist, a physician must have a background in
critical care medicine.
Hospitalists typically spend at least one-quarter of their time in a
hospital setting.
3. The following statement(s) can correctly be made about the hospitalist Go to

question
approach to inpatient care management:
4.
1. Management of inpatient care by hospitalists may significantly reduce

the length of stay and the total costs of care for a hospital admission
2. Most health plans that use hospitalists do so through a voluntary
hospitalist program
3. A hospitalist’s familiarity with utilization management (UM) and

quality management (QM) standards for inpatient care may reduce
unnecessary variations in care and improve clinical outcomes
All of the above
1 and 2 only
1 and 3 only
2 only
4. Health plans arrange for the delivery of various levels of healthcare,

including
1. Emergency care
Go to
2. Urgent care
question
3. Primary care delivered in a provider’s office 5.
In a ranking of these levels of care according to cost, beginning with the least
expensive level of care and ending with the most expensive level of care, the
correct order would be
1—2—3
2—3—1
3—1—2
3—2—1

Go to
question
The Balanced Budget Act (BBA) of 1997 established the use of ___________ 6.
to determine coverage of emergency services for Medicare and Medicaid
enrollees in health plans.
utilization management standards
the prudent layperson standard
preauthorization
diagnosis-based retrospective review
6. Nilay Sharma suffered a small wound while working in his yard and was
taken to a local hospital for treatment. A triage nurse at the hospital
Go to
evaluated Mr. Sharma’s condition and directed him to an outpatient unit in
question
the hospital where a physician assistant examined, cleaned, and sutured the 7.
wound. Mr. Sharma returned home following treatment. The care Mr. Sharma
received at the hospital is an example of the type of care known as
specialty referral
primary prevention
urgent care
emergency care
7. Elaine Newman suffered an acute asthma attack and was taken to a

hospital emergency department for treatment. Because Ms. Newman’s Go to
condition had not improved enough following treatment to warrant immediate question
release, she was transferred to an observation care unit. Transferring Ms. 8.
Newman to the observation care unit most likely
resulted in unnecessarily expensive charges for treatment
prevented Ms. Newman from receiving immediate attention for her
condition
gave Ms. Newman access to more effective and efficient treatment than
she could have obtained from other providers in the same region
allowed clinical staff an opportunity to determine whether Ms. Newman
required hospitalization without actually admitting her
8. Many health plans use clinical pathways to help manage the delivery of Go to
acute care services to plan members. One true statement about clinical question
pathways is that they 9.
determine which healthcare services are medically necessary and

appropriate for a particular patient in a particular situation
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
cover only services delivered in an acute inpatient setting
address medical conditions that affect a small segment of a given
population and with which the majority of providers are unfamiliar
Go to
9. In order to be effective, a clinical pathway must improve quality and
question
decrease costs. 10.
True
False
10. The Strathmore Health Plan uses clinical pathways to manage its acute
Back to
care services. In order to reduce the risk of financial liability associated with Top
the use of clinical pathways, Strathmore and its network hospitals should
base pathways on relevant evidence reported in medical literature
restrict each pathway to a single medical condition
use pathways to establish a new standard of care
allow providers to use only those interventions listed in the pathways
>---------- End of the Test ----------<
1 C
2 D
3 A
4 D
5 B
6 C
7 D
8 B
9 B
10 A
Reading 8B: Medical Management Strategies for Post-Acute Care
• Identify and describe the purposes of four types of post-acute care

• Explain how subacute care differs from skilled care
• Explain two types of advance directives
• Describe the role of a health plan in end-of-life care
Instructions:

Complete the Test

1. The case management team at the Hightower Health Plan reviewed the
medical records of the following two plan members to determine the type of
care each one needs and the most appropriate setting for that care:
• Ira Morton was hospitalized for a severe stroke. Although his medical
condition is stable, the stroke left him partially paralyzed and he will
require extensive rehabilitation and 24-hour medical care. Go to
• Theresa Finley is recovering from a total hip replacement and is in question
need of short-term physical therapy and twice-weekly visits from a 2.
licensed nurse to check her blood pressure and the healing of her
incision.
From the answer choices below, select the response that correctly identifies
the level of care that would be most appropriate for Mr. Morton and Ms.
Finley.
Mr. Morton-acute care Ms. Finley-subacute care
Mr. Morton-palliative care Ms. Finley-acute care
Mr. Morton-subacute care Ms. Finley-skilled care
Mr. Morton-skilled care Ms. Finley-palliative care
2. Health plans often use accreditation as a means of evaluating the quality Go to

of care delivered to plan members. Accreditation of subacute care providers is question
available from the 3.

Foundation for Accountability (FACCT)
3. The paragraph below contains two pairs of terms enclosed in parentheses. Go to

question
Select the term in each pair that correctly completes the paragraph. Then
4.
select the answer choice containing the two terms you have chosen.
A primary distinction between skilled care and subacute care relates to the
extent and medical complexity of the patient’s needs. Generally, subacute
care patients require (more / fewer) services from physicians and nurses and
(more / less) extensive rehabilitation services than do skilled care patients.
more / more
more / less
fewer / more
fewer / less
4. Skilled nursing facilities (SNFs) are required by law to have formal

programs for quality improvement and to monitor these programs using
established standards. These requirements are described in Go to
question
1. The Omnibus Budget Reconciliation Act (OBRA) of 1986 5.
2. The Balanced Budget Act (BBA) of 1997

Both 1 and 2
1 only
2 only
Neither 1 or 2
5. Home healthcare encompasses a wide variety of medical, social, and

support services delivered at the homes of patients who are disabled,
chronically ill, or terminally ill. The time period(s) when health plans typically
use home healthcare include Go to
question
6.
1. The period prior to a hospital admission
2. The period following discharge from a hospital

Both 1 and 2
1 only
2 only
Neither 1 nor 2
6. Demetrius Farrell, age 82, is suffering from a terminal illness and has Go to
question
consulted his health plan about the care options available to him. In order to
7.
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
medical power of attorney
patient assessment and care plan
living will
healthcare proxy
7. 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. Back to
Top
For this question, if answer choices (A) through (C) are all correct, select
Decisions regarding Mr. Farrell’s end-of-life care are legally the right and
responsibility of
Mr. Farrell and his family
Mr. Farrell’s physician
Mr. Farrell’s health plan
all of the above
>---------- End of the Test ----------<
1 C
2 B
3 A
4 B
5 A
6 C
7 A
Assignment 9: Medical Management Considerations for Pharmacy and Specialty Services
Reading 9A: Medical Management for Pharmacy Services-Part I
• Describe some of the advantages and disadvantages of using pharmacy benefit managers (PBMs) to develop and
manage pharmacy benefit programs
• Identify strategies that health plans can use to manage the way medications are priced and prescribed
• Describe three factors that impact prescription drug utilization
• Explain the difference between a two-tier and a three-tier copayment structure
• Describe five different types of analyses that are conducted in pharmoeconomic research
Instructions:

Complete the Test

1. Health plans that choose to contract with external organizations for
pharmacy services typically contract with pharmacy benefit managers
(PBMs). Functions that a PBM typically performs for a health plan include
Go to
1. Managing the costs of prescription drugs question
2. Promoting efficient and safe drug use 2.
3. Determining the health plan’s internal management responsibilities for

pharmacy services
All of the above
1 and 2 only
2 and 3 only
1 only
2. Economically, health plans cannot provide coverage for every drug

Go to
available from every manufacturer. As a result, purchaser contracts often
question
include provisions specifying that certain drugs or drug types will not be 3.
covered. These provisions are referred to as
limitations
exceptions
exclusions
drug edits

question
4.
or phrases that you have chosen.
The Millway Health Plan received a 15% reduction in the price of a particular
pharmaceutical based on the volume of the drug Millway purchased from the
manufacturer. This reduction in price is an example of a (rebate / price
discount) and (is / is not) dependent on actual provider prescribing patterns.
rebate / is
rebate / is not
price discount / is
price discount / is not
4. The following statements are about the use of provider profiling for Go to
pharmacy benefits. Three of the statements are true and one is false. Select question
the answer choice containing the FALSE statement. 5.
Health plans typically use provider profiles to improve the quality of care
associated with the use of prescription drugs.
Provider profiles identify prescribing patterns that fall outside normal
ranges.
Health plans can motivate providers to change their prescribing patterns
by sharing profile information with plan members and the general public.
Provider profiles are effective in modifying individual prescribing
patterns, but they have little effect on group prescribing patterns.
5. The Hall Health Plan gathered objective clinical information about the
recommended uses and dosages of angiotensin-converting enzyme (ACE)
Go to
inhibitors and presented the information to network providers to illustrate the
question
appropriate use of these frequently prescribed and expensive drugs. This 6.
information indicates that Hall most likely educated its network providers
through the use of
detailing
cognitive services
counterdetailing
drug efficacy study implementation (DESI)
6. Maxwell Midler’s health plan operates a drug formulary that includes a

typical three-tier copayment structure with required copayments of $5, $10,
Go to
and $25. Mr. Midler recently filled a prescription for a $75 drug that was not
question
included in the formulary. According to the plan’s formulary copayment 7.
structure, the amount that Mr. Midler was required to pay for his prescription
was
$5
$10
$25
$75
Go to
7. In recent years, the demand for prescription drugs has increased
question
dramatically. Factors that have contributed to this increase include 8.
increased education regarding the purpose and benefits of drug
formularies
reductions in the cost of prescription drugs
increased use of direct-to-consumer (DTC) advertising
all of the above
8. The Glenway Health Plan’s pharmacy and therapeutics (P&T) committee

conducted pharmacoeconomic research to measure both the clinical
Go to
outcomes and costs of two new cholesterol-reducing drugs. Results were
question
presented as a ratio showing the cost required to produce a 1 mcg/l decrease 9.
in cholesterol levels. The type of pharmacoeconomic research that Glenway
conducted in this situation was most likely
cost-effectiveness analysis (CEA)
cost-minimization analysis (CMA)
cost-utility analysis (CUA)
cost of illness analysis (COI)
9. The Noble Health Plan conducted a cost/benefit analysis of the following

four prescription drugs:
Benefit Cost
Drug A $525 $350
Drug B $450 $250 Back to
Drug C $400 $200 Top
Drug D $350 $100
According to this analysis, the drug that represents the most efficient use of
resources is
Drug A
Drug B
Drug C
Drug D
>---------- End of the Test ----------<
1 B
2 C
3 D
4 D
5 C
6 C
7 C
8 A
9 D
Reading 9B: Medical Management for Pharmacy Services-Part II
• List several functions that a health plan's pharmacy and therapeutics (P&T) committee performs
• List the five steps in performing DUR
• Describe the three types of DUR
• Explain the state laws related to mail-order pharmacies and generic substitution
Instructions:

Complete the Test

Go to
1. In most health plans, the formulary system is developed and managed by
question
a P&T committee. The P&T committee is responsible for 2.
evaluating and selecting drugs for inclusion in the formulary

overseeing the manufacture, distribution, and marketing of prescription
drugs
certifying the medical necessity of expensive, potentially toxic, or
nonformulary drugs
all of the above
2. Adele Stanley, a member of the Greenhouse Health Plan, recently went to

a network pharmacy to have a prescription filled. The pharmacist informed
Ms. Stanley that the prescribed drug was not in the plan formulary and that
reimbursement for the drug was not available except in extraordinary
circumstances. The pharmacist asked Ms. Stanley if she would accept a
generic substitute.
Go to
question
The paragraph below contains two pairs of terms enclosed in parentheses. 3.
Determine which term in each pair correctly completes the paragraph. Then
select the answer choice containing the two terms that you have chosen.
Greenhouse’s prescription drug reimbursement policy indicates that the plan

formulary is classified as (open / closed), and that compliance by patients
and providers is (mandatory / voluntary).
open / mandatory
open / voluntary
closed / mandatory
closed / voluntary
3. Adele Stanley, a member of the Greenhouse Health Plan, recently went to Go to

question
a network pharmacy to have a prescription filled. The pharmacist informed
4.
Ms. Stanley that the prescribed drug was not in the plan formulary and that
reimbursement for the drug was not available except in extraordinary
circumstances. The pharmacist asked Ms. Stanley if she would accept a
generic substitute.
If Ms. Stanley agrees to the generic substitution, she will receive a drug that
has not been tested for safety and efficacy in large clinical trials
is available without a prescription at a reasonable cost
has been classified by the Food and Drug Administration (FDA) as safe,
but that has not been proven fully effective
contains active ingredients that are identical to those of the prescribed
brand-name drug
4. Drugs included in a health plan’s formulary can be classified according to

Go to
how freely they can be prescribed. By definition, a drug that requires some
question
sort of review or approval by a plan physician or group of physicians before 5.
the prescription can be filled is
an unrestricted drug
a monitored drug
a restricted drug
a conditional drug
5. The Harbor Health Plan’s formulary policy encourages network pharmacists

Go to
who are asked to fill a prescription for a costly, brand-name drug to dispense
question
a different chemical entity within the same drug class in order to reduce 6.
costs. This type of drug substitution is referred to as
generic substitution, and prescriber approval is not required
generic substitution, and prescriber approval is always required
therapeutic substitution, and prescriber approval is not required
therapeutic substitution, and prescriber approval is always required
6. Step-therapy is a form of prior authorization that reserves the use of more

expensive medications for cases in which the use of less expensive
medications has been unsuccessful. Step-therapy is appropriate for situations
in which
Go to
question
1. A significant percentage of those treated with the initial therapy will 7.
require the second therapy
2. The delay created when a patient moves from one therapy to the next
therapy will not cause serious or permanent effects
Both 1 and 2
1 only
2 only
Neither 1 nor 2
Go to
7. One method that health plans use to address provider compliance with
question
formularies is academic detailing. 8.
True
False
8. One of the steps in drug utilization review (DUR) is defining optimal drug Go to
use, which can be accomplished by applying diagnosis criteria and drug- question
specific criteria. Drug-specific criteria are standards that identify the 9.
appropriate dosages, duration of treatment, and other elements related

to the use of a particular drug
actual prescribing and dispensing patterns for a particular drug
types of diseases, conditions, or patients for which a drug should be
used
cost-effectiveness of all possible drug treatments for a particular
condition
Go to
9. DUR can be conducted prospectively, concurrently, or retrospectively. One
question
true statement about prospective DUR is that it 10.
involves periodic audits of the medical records of a certain group of
patients
is based on historical data
focuses on the drug therapy for a single patient rather than overall
usage patterns
is conducted by physicians, without input from pharmacists
10. All states have laws describing the conditions under which pharmacists Go to
can substitute a generic drug for a brand-name drug. With respect to these question
laws, it is correct to say that in every state, 11.
pharmacists must obtain physician approval before substituting generics

for brand-name drugs
pharmacists must obtain authorization from the health plan before
substituting generics for brand-name drugs
prescribers must obtain authorization from the health plan before
prescribing a brand-name drug
prescribers have some mechanism that allows them to prevent
pharmacists from substituting generics for brand-name drugs
Back to
11. PBMs are accredited by the same organizations that accredit health plans. Top
True
False
>---------- End of the Test ----------<

1 A
2 C
3 D
4 B
5 D
6 C
7 A
8 A
9 C
10 D
11 B
Reading 9C: Medical Management for Specialty Services
• Explain why a health plan might choose to use a carve-out arrangement to deliver a specialty service
• Describe several medical management challenges for behavioral healthcare
• Explain the strategies that health plans and managed behavioral healthcare organizations use to manage quality and
costs for behavioral healthcare
• Understand quality and utilization management strategies for dental care, vision care, and complimentary and
alternative medicine
Instructions:

Complete the Test

1. One way that health plans can make their benefits more appealing to Go to
employers and employees is to offer coverage for specialty services. It is question
correct to say that specialty services typically 2.
involve the same types of providers and delivery systems as do standard

medical services
are a subset of a health plan’s standard medical-surgical services
are not monitored by health plans for quality or utilization
require specialized knowledge for service delivery and management
2. The nature of behavioral healthcare creates unique medical management Go to

challenges for health plans. One method health plans have used to support question
the delivery of appropriate services in a cost-effective manner is to 3.
remove behavioral healthcare services from the primary care setting

shift behavioral healthcare from acute inpatient settings to alternative
settings when feasible
reserve the use of psychotherapy for treatment of those conditions that
persist over long periods of time or for the life of the patient
offer the same level of compensation to all of the professional disciplines
that provide behavioral healthcare services to plan members
3. The Shoreside Health Plan recently added coverage for behavioral Go to

question
healthcare services to its benefit package. In order to support the quality of
4.
its behavioral healthcare services, Shoreside plans to seek accreditation for
its behavioral healthcare program. Accreditation specifically designed for
behavioral healthcare programs is available through
1. The Joint Commission on Accreditation of Healthcare Organizations

(JCAHO)
2. The National Committee for Quality Assurance (NCQA)
3. The American Accreditation HealthCare Commission/URAC (URAC)

All of the above
1 and 2 only
2 and 3 only
1 only
4. The Mental Health Parity Act (MHPA) of 1996 is a federal law that Go to
establishes requirements for behavioral healthcare coverage for group plan question
members. The MHPA 5.
requires health plans to offer mental health benefits to all eligible

members
prohibits health plans that offer mental health benefits from imposing
lower annual or lifetime dollar limits on mental illnesses than they do on
physical illnesses
provides an exemption for health plans that can demonstrate cost
savings of more than 1 percent
prohibits health plans from limiting the number of outpatient visits or
inpatient days covered under the plan
Go to
5. The following statements are about medical management considerations
question
for dental care. Select the answer choice containing the correct statement. 6.
Managed dental care organizations are regulated at the state rather than
the federal level.
Dental care differs from medical care in that most dental care is
provided by specialists.
Dental preferred provider organizations (Dental PPOs) are subject to
more regulation than are dental health maintenance organizations
(DHMOs).
Managed dental plans are accredited by the National Association of
Dental Plans (NADP).
6. Michelle Durden, who is enrolled in a dental health maintenance Go to

organizations (DHMO) offered by her employer, is due for a routine dental question
examination. If the plan is typical of most DHMOs, then Ms. Durden 7.
must pay the entire cost of the examination

must obtain a referral to a dentist from her primary care provider (PCP)
can schedule the examination without preauthorization of payment by
the DHMO
can schedule an unlimited number of examinations and cleanings per
year
7. Vision care is typically separated into two categories: routine eye care and Go to
question
clinical eye care. The standard benefit plans offered by most health plans
8.
include coverage for
1. Routine eye care
2. Clinical eye care

Both 1 and 2
1 only
2 only
Neither 1 nor 2
Go to
8. Health plans that offer complementary and alternative medicine (CAM)
question
services face potential liability because many types of CAM services 9.
must be offered as separate supplemental benefits or separate products

lack clinical trials to evaluate their safety and effectiveness
are not covered by state or federal consumer protection statutes
focus on a specific illness, injury, or symptom rather than on the whole
body
9. Examples of alternative healthcare practitioners are chiropractors,

Go to
naturopaths, and acupuncturists. The only well-established credentialing
question
standards for alternative healthcare practitioners are those available from 10.
NCQA. These NCQA credentialing standards apply to
chiropractors
naturopaths
acupuncturists
all of the above
10. Most health plans require a PCP referral or precertification for CAM Back to
benefits. Top
True
False
>---------- End of the Test ----------<
1 D
2 B
3 B
4 B
5 A
6 C
7 C
8 B
9 A
10 B
Assignment 10: Medical Management for Government-Sponsored Programs
Reading 10A: Medicare
• Identify the major benefits of managed Medicare

• Understand the legal and regulatory requirements that affect medical management for Medicare
• Recognize the special health risk factors and needs of the Medicare population
• Describe the important components of a comprehensive program of geriatric care
Instructions:

Complete the Test

1. Medicare beneficiaries can obtain healthcare benefits through fee-for-
Go to
service (FFS) Medicare programs, Medicare medical savings account (MSA)
question
plans, Medigap insurance, or coordinated care plans (CCPs). Unlike other 2.
coverage options, CCPs
provide only those benefits covered by Medicare Part A and Part B
are not subject to federal or state regulation
place primary care at the center of the delivery system
are structured as indemnity plans
2. Since its inception, Medicare has undergone a number of changes because Go to

of legal and regulatory action. One result of the Balanced Budget Act (BBA) of question
1997 has been to 3.
expand Medicare benefits by mandating coverage for certain preventive

services
reduce the number of organizations that can deliver covered services
encourage growth of managed Medicare programs in all markets
increase the number of “zero premium” plans available to Medicare
beneficiaries
Go to
The QAPI (Quality Assessment Performance Improvement Program) is a question
Centers for Medicaid and Medicare Services (CMS) initiative designed to 4.
strengthen health plans’ efforts to protect and improve the health and
satisfaction of Medicare beneficiaries. QAPI quality assessment standards
apply to
standard medical-surgical services
mental health and substance abuse services
services offered to Medicare enrollees as optional supplementary benefits
all of the above
4. Comparing the quality of managed Medicare programs with the quality of Go to

FFS Medicare programs is often difficult. Unlike FFS Medicare, managed question
Medicare programs 5.
can measure and report quality only at the provider level

use a single system to deliver services to all plan members
provide an organizational focus for accountability
can use the same performance measures for all products and plans
5. Designing effective medical management programs for Medicare

Go to
beneficiaries requires an understanding of the unique health needs of the
question
Medicare population. One characteristic of Medicare beneficiaries is that they 6.
typically
do not experience mental health problems
consume more than half of all prescription drugs
are likely to equate quality with the technical aspects of clinical
procedures
require longer and more costly recovery periods following acute illnesses
or injuries than does the general population
6. The paragraph below contains two pairs of phrases enclosed in

parentheses. Select the phrase in each pair that correctly completes the
paragraph. The select the answer choice containing the two phrases you have
selected.
Go to
question
Calvin Montrose, age 75, has difficulty performing basic self-care activities, 7.
such as bathing, dressing, and eating, without assistance. This information
indicates that Mr. Montrose needs assistance with (activities of daily living /
instrumental activities of daily living) that are used to measure his (functional
status / health status).
activities of daily living / functional status
activities of daily living / health status
instrumental activities of daily living / functional status
instrumental activities of daily living / health status
7. Health plans that offer healthcare programs for Medicare beneficiaries have
Go to
a strong financial incentive for identifying high-risk seniors as early as
question
possible. The identification of high-risk seniors is typically accomplished 8.
through the use of
case management
geriatric evaluation and management (GEM)
intervention identification
interdisciplinary home care (IHC)
8. CMS has developed two prototype programs—Programs of All-inclusive

Care for the Elderly (PACE) and the Social Health Maintenance Organization
Back to
(SHMO) demonstration project—to deliver healthcare services to Medicare Top
beneficiaries. From the answer choices below, select the response that
correctly identifies the features of these programs.
PACE-annual limits on benefits for nursing home and community-based
care SHMO-no limits on long-term care benefits
PACE-provide long-term care only SHMO-provide acute and long-term
care
PACE-enrollees must be age 65 or older SHMO-enrollees must be age
55 or older
PACE-enrollment open to nursing home certifiable Medicare beneficiaries
only SHMO-enrollment open to all Medicare beneficiaries
>---------- End of the Test ----------<
1 C
2 A
3 D
4 C
5 D
6 A
7 C
8 D
Reading 10B: Medicaid
• Describe the impact of recent laws and regulations on the management of medical care for Medicaid recipients
• Describe the health risk factors and healthcare needs of Medicaid recipients
• Identify the essential components of an effective Medicaid health plan plan
• Describe the challenges health plans face in designing programs to meet the needs of Medicaid recipients
Instructions:

Complete the Test

1. Recent laws and regulations have established new requirements for Go to
Medicaid eligibility. The Personal Responsibility and Work Opportunity question
Reconciliation Act (PRWORA) of 1996 affected Medicaid eligibility by 2.
severing the link between Medicaid and public assistance

eliminating the need for applications for Medicaid and public assistance
allowing states to provide healthcare benefits to groups outside the
traditional Medicaid population
providing supplemental funding for dual eligibles in the form of five-year
block grants
2. The BBA of 1997 allows states to provide Medicaid benefits to children

through the State Children’s Health Insurance Program (SCHIP). Under the
terms of the BBA, states can implement SCHIP as Go to
question
1. Part of their existing Medicaid programs 3.
2. Separate commercial insurance programs

Both 1 and 2
1 only
2 only
Neither 1 nor 2
3. The following statements are about QAPI as it applies to Medicare+Choice Go to

plans and Medicaid health plan entities. Select the answer choice containing question
the correct statement. 4.
QAPI provides separate sets of standards for Medicaid MCEs and

Medicare+Choice plans.
Medicaid primary care case management (PCCM) programs are required
to comply with all QAPI standards.
QISMC standards for quality measurement and improvement apply only
to clinical services delivered to Medicare and Medicaid enrollees.
States that require Medicaid MCEs to comply with QAPI standards are
considered to be in compliance with CMS quality assessment and
improvement regulations.
4. The Medicaid population can be divided into subgroups based on their

relative size and the costs of providing benefits. From the answer choices
Go to
below, select the response that correctly identifies the subgroups that
question
represent the largest percentages of the total Medicaid population and of 5.
total Medicaid expenditures. Largest % of Medicaid Population- Largest
% of Medicaid Expenditures-
Largest % of Medicaid Population-dual eligibles Largest % of
Medicaid Expenditures-children and low-income adults
Largest % of Medicaid Population-chronically ill or disabled
individuals not eligible for MedicareLargest % of Medicaid
Expenditures-dual eligibles
Largest % of Medicaid Population-children and low-income adults
Largest % of Medicaid Expenditures-chronically ill or disabled
individuals not eligible for Medicare
Largest % of Medicaid Population-chronically ill or disabled
individuals not eligible for Medicare Largest % of Medicaid
Expenditures-children and low-income adults
5. The following statements are about chronic and disabling conditions among Go to
children eligible for Medicaid. Three of the statements are true and one is question
false. Select the answer choice containing the FALSE statement. 6.
Children with chronic conditions use more physician and nonphysician

professional services than do children in the general population.
The majority of chronic conditions affecting children in Medicaid
programs are the same as those affecting children in the general
population.
Medicaid-eligible children are at risk for serious mental and physical
conditions.
Children in Medicaid programs have a higher incidence of chronic
disabling conditions than do children in the general population.

Go to
The key to successfully managing the quality and cost-effectiveness of question
7.
healthcare services for Medicaid enrollees is to merge Medicaid recipients into
existing plans.
True
False
7. Access to services is an important issue for both fee-for-service (FFS)

Back to
Medicaid and managed Medicaid programs. Access to services under Top
managed Medicaid is affected by the
lack of qualified providers in provider networks
lack of resources necessary to establish case management programs for
patients with complex conditions
unstable eligibility status of Medicaid recipients
inability of Medicaid recipients to change health plans or PCPs
>---------- End of the Test ----------<
1 A
2 A
3 D
4 C
5 B
6 B
7 C
Reading 10C: Other Government-Sponsored Healthcare Programs
• Identify several FEHBP requirements that impact a health plan's medical management activities
• Describe how the Military Health System and the Veterans Health Administration influence healthcare quality and
cost in the private sector, and vice versa
• Discuss key differences between workers' compensation programs and group healthcare programs in terms of
quality management and cost management.
Instructions:

Complete the Test

1. The following statement(s) can correctly be made about medical
management considerations for the Federal Employee Health Benefits
Program (FEHBP):
Go to
1. FEHBP plan members who have exhausted the health plan’s usual
question
appeals process for a disputed decision can request an independent 2.
review by the Office of Personnel Management (OPM)
2. All health plans that cover federal employees are required to develop
and implement patient safety initiatives
Both 1 and 2
1 only
2 only
Neither 1 nor 2
2. Serena Wilson, a registered nurse, is employed at a TRICARE Service

Center (TSC) located at a military installation. Ms. Wilson serves as a primary Go to
point of contact between enrollees and the TRICARE system and answers question
enrollees’ questions about plan options, eligibility, provider selection, and 3.
claims. This information indicates that Ms. Wilson serves as a
lead agent
beneficiary services representative
health plan support contractor
primary care manager (PCM)

question
parentheses. Select the term or phrase in each pair that correctly completes
4.
the paragraph. Then select the answer choice containing the two terms or
phrases you have chosen.
TRICARE enrollees have the right to challenge authorization and coverage

decisions. Such challenges are referred to as (appeals / grievances) and are
typically handled by the (TRICARE contractor / Area Field Office).
appeals / TRICARE contractor
appeals / Area Field Office
grievances / TRICARE contractor
grievances / Area Field Office
4. The delivery of quality, cost-effective healthcare is a primary goal of both

Go to
group healthcare and workers’ compensation programs. One difference
question
between group healthcare and workers’ compensation is that workers’ 5.
compensation
provides health and disability benefits to employees injured on the job
only if the employer is at fault for the injury
provides coverage for a variety of direct and indirect healthcare,
disability, and workplace costs
manages costs by including employee cost-sharing features in its benefit
design
places limits on benefits by restricting the amount of benefit payments
or the number of covered hospital days or provider office visits
answer choice (D). Otherwise, select the one correct answer choice. Go to
question
6.
Ways that workers’ compensation health plans can help control the costs of
job-related injuries and illnesses include
applying strict definitions of medical necessity
developing prevention and recovery programs
applying out-of-network benefit reductions
all of the above
6. Occasionally, employers combine workers’ compensation, group

Back to
healthcare, and disability programs into an integrated product known as 24- Top
hour coverage. One true statement about 24-hour coverage is that it typically
increases administrative costs
requires plans to maintain separate databases of patient care
information
exempts plans from complying with state workers’ compensation
regulations
allows plans to apply disability management and return-to-work
techniques to nonoccupational conditions
>---------- End of the Test ----------<

1 A
2 B
3 A
4 B
5 B
6 D

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Assignment 1: The Medical Management Function

Reading 1A: The Role of Medical Management in a health plan

1. Select or enter the best answer for each of the 7 questions.

2. Determine whether the following statement is true or false:

3. With respect to the activities of MCO medical directors, it is correct to Go to

5. Determine whether the following statement is true or false:

7. MCOs usually have a formal program for the oversight of delegated

>---------- End of the Test ----------<

1. Select or enter the best answer for each of the 6 questions.

Complete the Test

2. To facilitate electronic commerce (eCommerce), a health plan may Go to

based on Web-based technologies

5. The paragraph below contains an incomplete statement. Select the answer

6. One method of transferring the information in electronic medical records

1. Select or enter the best answer for each of the 11 questions.

Complete the Test

1. For both health maintenance organizations (HMOs) and non-HMO

2. Because of employers’ concern about the quality and costs of

Medicare and TRICARE programs

• Provision 1—Limits damage awards in lawsuits related to

• Provision 2—Establishes electronic data security standards, which

4. The Quality Assessment Performance Improvement (QAPI) is a quality

Health Resources and Services Administration (HRSA)

Health Resources and Services Administration (HRSA)

Health Resources and Services Administration (HRSA)

9. Accreditation is intended to help purchasers and consumers make

10. The following statement(s) can correctly be made about accrediting Go to

1. The National Committee for Quality Assurance (NCQA) allows health

2. In some cases, accreditation standards for delegation oversight are

11. Various government and independent agencies have created tools to

>---------- End of the Test ----------<

Reading 2A: Clinical Practice Management

• Describe the components of a health plan's coverage policy

1. Select or enter the best answer for each of the 7 questions.

Complete the Test

2. Three general categories of coverage policy—medical policy, benefits

1. In case of conflict between the purchaser contract and a health plan’s

3. All of the criteria for coverage decisions must be included in the

In this situation, the prescribing of Upzil for Ms. Ray’s headaches is an

1. Harbrace’s medical policy most likely establishes the procedure that

6. The following statements are about health plans’ development of medical Go to

Technology assessment is applicable only to medical policy development

>---------- End of the Test ----------<

Reading 3A: Quality Management

• Describe the major steps in the quality management process

1. Select or enter the best answer for each of the 8 questions.

Complete the Test

1. The goal of outcomes management is to identify and implement

2. Outcomes management introduces performance as a critical factor in

4. The paragraph below contains two pairs of terms in parentheses.

5. Determine whether the following statement is true or false:

6. This agency’s accreditation decisions are based on the results of an on-site

7. Among this agency’s accreditation programs are accreditation for preferred

1. The complexity of modern medicine and healthcare delivery systems

3. Provider compliance with internal incident reporting requirements is

>---------- End of the Test ----------<

• Describe the major components of a quality assessment program

1. Select or enter the best answer for each of the 9 questions.

Complete the Test

3. The paragraph below contains an incomplete statement. Select the answer Go to

Each quality standard used by a health plan is associated with quality

4. In order to provide a true measure of quality, the data collected by a

5. The following statement(s) can correctly be made about performance