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AHM-250
Healthcare Management: An Introduction Questions and Answers

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Questions # 11:

In order to help review its institutional utilization rates, the Sahalee Medical Group, a health plan, uses the standard formula to calculate hospital bed days per 1,000 plan members for the month to date (MTD). On April 20, Sahalee used the following inf

Options:

274

365

1,000

Answer

Questions # 12:

In order to cover some of the gap between FFS Medicare coverage and the actual cost of services, beneficiaries often rely on Medicare supplements. Which of the following statements about Medicare supplements is correct?

Options:

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

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

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

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

Answer

Questions # 13:

Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.

Options:

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

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

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

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

Answer

Questions # 14:

In the paragraph below, a sentence contains two pairs of words enclosed in parentheses. Determine which word in each pair correctly completes the sentence. Then select the answer choice containing the two words that you have chosen. Many pharmacy benefit

Options:

Therapeutic / always

Generic / always

Generic / never

Therapeutic / never

Answer

Questions # 15:

HMOs typically employ several techniques to manage provider utilization and member utilization of medical services. One technique that an HMO uses to manage member utilization is

Options:

the use of physician practice guidelines

the requirement of copayments for office visits

capitation

risk pools

Answer

Questions # 16:

As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members:

Brad Van Note, age 28, is taking many different, costly medications for

Options:

Mr. Van Note, Mr. Albrecht, and Ms. Cromartie

Mr. Van Note and Ms. Cromartie only

Mr. Van Note and Mr. Albrecht only

Mr. Albrecht and Ms. Cromartie only

Answer

Questions # 17:

A health savings account must be coupled with an HDHP that meets federal requirements for minimum deductible and maximum out-of-pocket expenses. Dollar amounts are indexed annually for inflation. For 2006, the annual deductible for self-only coverage must

Options:

$525

$1,050

$2,100

$5,250

Answer

Questions # 18:

In addition to the credentialing activities that an health plan performs when initially accepting a provider into its network, the health plan must also perform recredentialing of the same providers on an ongoing basis. Many of the same activities are per

Options:

verification of a network provider's medical education and residency

performance of site inspections in a provider's facilities

review of information from a provider's quality improvement activities

verification of a provider's licensure and certification

Answer

Questions # 19:

From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence

Options:

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

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

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

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

Answer

Questions # 20:

In health plan terminology, demand management, as used by health plans, can best be described as

Options:

an evaluation of the medical necessity, efficiency, and/or appropriateness of healthcare services and treatment plans for a given patient

a series of strategies designed to reduce plan members' needs to utilize healthcare services by encouraging preventive care, wellness, member self-care, and appropriate use of healthcare services

a technique that prevents a provider who is being reimbursed under a fee schedule arrangement from billing a plan member for any fees that exceed the maximum fee reimbursed by the plan

a system of identifying plan members with special healthcare needs, developing a healthcare strategy to meet those needs, and coordinating and monitoring the care

Answer

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