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AHM-250
Healthcare Management: An Introduction Questions and Answers

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Viewing questions 51-60 out of questions

Questions # 51:

More procedures or services may be fully covered within the PPO network than those out of network.

Options:

True

False

Answer

Questions # 52:

Phillip Tsai is insured by both a indemnity health insurance plan, which is his primary plan, and a health plan, which is his secondary plan. Both plans have typical coordination of benefits (COB) provisions, but neither has a nonduplication of benefits p

Options:

$300

$400

$900

Answer

Questions # 53:

The following programs are part of the Alcove Health Plan's utilization management (UM) program:

Preventive care initiatives

A telephone triage program

A shared decision-making program

A self-care program

With regard to the UM programs, it is most

Options:

Preventive care initiatives include immunization programs but not health promotion programs.

Telephone triage program is staffed by physicians only.

Shared decision-making program is appropriate for virtually any medical condition.

Self-care program is intended to complement physicians' services, rather than to supersede or eliminate these services.

Answer

Questions # 54:

The criteria used to identify and measure healthcare quality are generally divided into three categories: structure, process, and outcomes measures. Structure measures, which relate to the nature and quality of the resources that a health plan has available

Options:

length of time patients have to wait at the office to be seen by a provider

percentage of plan physicians who are board-certified

percentage of children receiving immunizations

number of patients contracting an infection in the hospital

Answer

Questions # 55:

The Citywide Health Group is a large provider-based health plan that includes physician groups, hospitals, and other facilities. In order to oversee and manage the operation of the organization, Citywide has established an enterprise scheduling system. The

Options:

provide information to Citywide's management regarding provider licensure, certification, and malpractice history

detect instances of overutilization, underutilization, or inappropriate utilization of medical resources

allow Citywide's different components to function as a single organization in arranging access to facilities and resources

facilitate the processing of requests for authorization of payment of benefits

Answer

Questions # 56:

One typical characteristic of preferred provider organization (PPO) benefit plans is that PPOs:

Options:

Assume full financial risk for arranging medical services for their members.

Require plan members to obtain a referral before getting medical services from specialists.

Use a capitation arrangement, instead of a fee schedule, to reimburse physicians.

Offer some coverage, although at a higher cost, for plan members who choose to use the services of non-network providers.

Answer

Questions # 57:

Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involves

Options:

ascertaining that physicians in the plan have the necessary and appropriate credentials to prescribe medications

compiling data on physician prescribing patterns and comparing physicians' actual prescribing patterns to expected patterns within select drug categories

monitoring patient-specific drug problems through concurrent and retrospective review

establishing protocols that require physicians to obtain certification of medical necessity prior to drug dispensing

Answer

Questions # 58:

The Courtland PPO maintains computerized records that include clinical, demographic, and administrative data about individual plan members. The data in these records is available to plan providers, ancillary service departments, pharmacies, and others inv

Options:

a data warehouse

a decision support system

an outsourcing system

an electronic medical record (EMR) system

Answer

Questions # 59:

The following sentence contains an incomplete statement with two missing words. Select the answer choice that contains the words that correctly fill the two blanks, respectively. The philosophy of consumer choice involves having consumers play a(n) ______