AHM-540 Online Practice Questions and Answers

The following statement(s) can correctly be made about performance measurement systems:

1.The most difficult purpose for a performance measurement system to address is to measure changes in outcomes caused by modifications in administrative or clinical treatment processes

2.A

health plan needs different performance measurement systems to evaluate its administrative services and the clinical performance of its providers

A.

Both 1 and 2

B.

1 only

C.

2 only

D.

Neither 1 nor 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.

The paragraph below contains two pairs of terms enclosed 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.

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).

A. open / mandatory

B. open / voluntary

C. closed / mandatory

D. closed / voluntary

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 financial situation

2.Case management generally requires a less comprehensive and 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

A. All of the above

B. 1 and 2 only

C. 2 and 3 only

D. 1 only

Health plans conduct evaluations on the efficiency and effectiveness of their quality improvement activities. With regard to the effectiveness of quality improvement plans, it is correct to say that

A. effectiveness is the relationship between what the organization puts into an improvement plan and what it gets out of the plan

B. effectiveness is measured by reviewing outcomes to determine the accuracy or appropriateness of the strategy and the adequacy of resources allocated to that strategy

C. the effectiveness of an action plan is typically measured with a concurrent evaluation

D. 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

The Brighton Health Plan regularly performs prospective UR for surgical procedures. Brighton's prospective UR activities are likely to include

A. documenting the clinical details of the patient's condition and care

B. tracking the length of inpatient stay

C. completing the discharge planning process

D. determining the most appropriate setting for the proposed course of care

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

A. All of the above

B. 1 and 2 only

C. 1 and 3 only

D. 3 only

Medicare beneficiaries can obtain healthcare benefits through fee-for-service (FFS) Medicare programs, Medicare medical savings account (MSA) plans, Medigap insurance, or coordinated care plans (CCPs).

Unlike other coverage options, CCPs

A. provide only those benefits covered by Medicare Part A and Part B

B. are not subject to federal or state regulation

C. place primary care at the center of the delivery system

D. are structured as indemnity plans

In order to provide a true measure of quality, the data collected by a quality indicator should accurately represent the service dimension being measured. This information indicates that the indicator should exhibit the characteristic known as

A. clarity

B. reliability

C. validity

D. feasibility

The Fairview Health Plan uses a dual database approach to integrate information needed for its disease management program. This information indicates that Fairview uses an information management system that

A. combines all existing information from all data sources into a single comprehensive system

B. connects multiple databases with a central interface engine that acts as an information clearinghouse

C. provides an outside vendor with pertinent data that the vendor compiles into an integrated database

D. 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

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

A. utilization review (UR)

B. quality management (QM)

C. preventive health services

D. all of the above