The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self- care most likely would not be appropriate.
A. 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.
B. Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day.
C. Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility.
D. Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.
The Medicaid population can be divided into subgroups based on their relative size and the costs of providing benefits. From the answer choices below, select the response that correctly identifies the subgroups that represent the largest percentages of the total Medicaid population and of total Medicaid expenditures. Largest % of Medicaid Population- Largest % of Medicaid Expenditures-
A. Largest % of Medicaid Population-dual eligibles Largest % of Medicaid Expenditures- children and low-income adults
B. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for MedicareLargest % of Medicaid Expenditures-dual eligibles
C. Largest % of Medicaid Population-children and low-income adults Largest % of Medicaid Expenditures-chronically ill or disabled individuals not eligible for Medicare
D. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for Medicare Largest % of Medicaid Expenditures-children and low-income adults
One difference between outcomes research and clinical research is that outcomes research
A. provides an absolute measure of treatment results, whereas clinical research provides a relative measure of results
B. focuses on treatment effectiveness, whereas clinical research focuses on treatment efficacy
C. examines diseases and treatments in isolation, whereas clinical research considers the effects of changes in health status and quality of life
D. gathers outcomes data from controlled clinical trials, whereas clinical research collects and analyzes clinical, financial, and administrative data
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
The Balanced Budget Act (BBA) of 1997 established the use of ___________ to determine coverage of emergency services for Medicare and Medicaid enrollees in health plans.
A. utilization management standards
B. the prudent layperson standard
C. preauthorization
D. diagnosis-based retrospective review
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.
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.
A. medical policy / can
B. medical policy / cannot
C. contract provision / can
D. contract provision / cannot
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 1.The Omnibus Budget Reconciliation Act (OBRA) of 1986 2.The Balanced Budget Act (BBA) of 1997
A. Both 1 and 2
B. 1 only
C. 2 only
D. Neither 1 or 2
The Strathmore Health Plan uses clinical pathways to manage its acute care services. In order to reduce the risk of financial liability associated with the use of clinical pathways, Strathmore and its network hospitals should
A. base pathways on relevant evidence reported in medical literature
B. restrict each pathway to a single medical condition
C. use pathways to establish a new standard of care
D. allow providers to use only those interventions listed in the pathways
Various government and independent agencies have created tools to measure and report the quality of healthcare. One performance measurement tool that was developed by the Agency for Healthcare Research and Quality (AHRQ) is
A. the Health Plan Employer Data and Information Set (HEDIS?, which is a report card system for hospitals and long-term care facilities
B. HEDIS, which is a performance measurement tool that addresses both effectiveness of care and plan member satisfaction
C. the Consumer Assessment of Health Plans (CAHPS?, which was established to develop and implement a national strategy for quality measurement and reporting
D. CAHPS, which is a tool that measures consumer satisfaction with specific aspects of health plan services
Health plans arrange for the delivery of various levels of healthcare, including 1.Emergency care 2.Urgent care 3.Primary care delivered in a provider's office 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
A. 1--2--3
B. 2--3--1
C. 3--1--2
D. 3--2--1
Economically, health plans cannot provide coverage for every drug available from every manufacturer. As a result, purchaser contracts often include provisions specifying that certain drugs or drug types will not be covered. These provisions are referred to as
A. limitations
B. exceptions
C. exclusions
D. drug edits
