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For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say
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.
The following statement(s) can correctly be made about Harbrace’s use of 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
Drugs included in a health plan’s formulary can be classified according to how freely they can be prescribed. By definition, a drug that requires some sort of review or approval by a plan physician or group of physicians before the prescription can be filled is
The following statement(s) can correctly be made about medical management considerations for the Federal Employee Health Benefits Program (FEHBP):
1. FEHBP plan members who have exhausted the health plan’s usual appeals process for a disputed decision can request an independent 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
The following statements are about chronic and disabling conditions among children eligible for Medicaid. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
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.
Health plans use both internal and external standards to assess the quality of 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.
This agency oversees the Federal Employee Health Benefits Program (FEHBP).
Comorbidity can have a significant impact on the effective implementation of disease management programs. Comorbidity can correctly be defined as the
The following statements are about the characteristics of a utilization review (UR) program. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
One way that health plans can make their benefits more appealing to employers and employees is to offer coverage for specialty services. It is correct to say that specialty services typically
A health plan’s choice of structure measures, process measures, and outcome measures to evaluate performance depends in part on the scientific soundness of the measures. One approach that a health plan can use to enhance scientific soundness is stratification, which refers to the
Comparing the quality of managed Medicare programs with the quality of FFS Medicare programs is often difficult. Unlike FFS Medicare, managed Medicare programs
Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services
Benchmarking is a quality improvement strategy used by some health plans. With regard to benchmarking, it is correct to say that
The following statement(s) can correctly be made about accrediting agency standards for delegation:
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
The Hall Health Plan gathered objective clinical information about the recommended uses and dosages of angiotensin-converting enzyme (ACE) inhibitors and presented the information to network providers to illustrate the appropriate use of these frequently prescribed and expensive drugs. This information indicates that Hall most likely educated its network providers through the use of
For this question, if answer choices (1) through (3) are all correct, select answer choice (4). Otherwise, select the one correct answer choice.
Health plans sometimes delegate selected medical management activities to their providers or other external entities. Activities that are frequently delegated include
Determine whether the following statement is true or false:
All health plans participating in the Federal Employee Health Benefits Program (FEHBP) are required to use the Consumer Assessment of Health Plans (CAHPS) to measure customer satisfaction.
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.
The Glenway Health Plan’s pharmacy and therapeutics (P&T) committee conducted pharmacoeconomic research to measure both the clinical outcomes and costs of two new cholesterol-reducing drugs. Results were presented as a ratio showing the cost required to produce a 1 mcg/l decrease in cholesterol levels. The type of pharmacoeconomic research that Glenway conducted in this situation was most likely
Emilio Martinez, a member of the Bloom Health Plan, has recently been 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
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 increases patients’ exposure to the risks of medical errors
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
Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located at a military installation. Ms. Wilson serves as a primary point of contact between enrollees and the TRICARE system and answers enrollees’ questions about plan options, eligibility, provider selection, and claims. This information indicates that Ms. Wilson serves as a
The Harbor Health Plan’s formulary policy encourages network pharmacists who are asked to fill a prescription for a costly, brand-name drug to dispense a different chemical entity within the same drug class in order to reduce costs. This type of drug substitution is referred to as