Managed Care and Insurance Exam 3
UPDATED QUESTIONS AND CORRECT
ANSWERS
UM focuses on telling doctors and hospitals what to do. - CORRECT
ANSWER FALSE
The use of utilization guidelines targets only managed care patients and does not have an
impact on the care of non-managed care patients. - CORRECT ANSWER FALSE
Nurse-on-call or medical advice programs are considered demand management strategies. -
CORRECT ANSWER TRUE
Utilization management seeks to reduce practice variation while promoting good outcomes
and _____. - CORRECT ANSWER None of the above
Which of the following is an example of an ancillary service - CORRECT
ANSWER cardiac testing
cardiac rehabilitation
What is a formulary? - CORRECT ANSWER A list of drugs covering typical medical
needs
Hospital utilization varies by geographical area. - CORRECT ANSWER TRUE
What is the term that describes pre-certification used for costly drugs for which reasonable
alternatives exist? - CORRECT ANSWER Step Therapy
Which of the following is an example of prospective utilization management? - CORRECT
ANSWER Referral Management
, "Medical Necessity" is a factor in coverage determinations when medical good or services
may or may not be covered depending on certain criteria. - CORRECT
ANSWER TRUE
Which of the following can be used to measure utilization? - CORRECT
ANSWER Per-member-per-year metrics
Average length of stay
Bed days per 1,000
Which of the following reasons might be used to exclude a type of service based on medical
necessity? - CORRECT ANSWER Both A&B
Which of the following is a is recognized as an accreditation organization for payers and
managed care organizations? - CORRECT ANSWER -National Committee for Quality
Assurance (NCQA)
-URAC (Utilization Review Accreditation Commission)
-Accreditation Association for Ambulatory Health Care (AAAHC)
Which of the following is an example of a measure used by an accrediting program? -
CORRECT ANSWER -network adequacy
-provider credentialing
-the Consumer Assessment of Health Providers & Systems (CAHPS) survey
The Donabedian model classifies quality activities into which three broad and interrelated
categories? - CORRECT ANSWER Structure, process, outcome
Outcome measures focus on the context in which care and services are provided (not how the
care is provided or the result of that care) - CORRECT ANSWER FALSE
Which of the following is one of the Institute of Medicine (IOM) six goals for providing
quality health care? - CORRECT ANSWER Equitable
UPDATED QUESTIONS AND CORRECT
ANSWERS
UM focuses on telling doctors and hospitals what to do. - CORRECT
ANSWER FALSE
The use of utilization guidelines targets only managed care patients and does not have an
impact on the care of non-managed care patients. - CORRECT ANSWER FALSE
Nurse-on-call or medical advice programs are considered demand management strategies. -
CORRECT ANSWER TRUE
Utilization management seeks to reduce practice variation while promoting good outcomes
and _____. - CORRECT ANSWER None of the above
Which of the following is an example of an ancillary service - CORRECT
ANSWER cardiac testing
cardiac rehabilitation
What is a formulary? - CORRECT ANSWER A list of drugs covering typical medical
needs
Hospital utilization varies by geographical area. - CORRECT ANSWER TRUE
What is the term that describes pre-certification used for costly drugs for which reasonable
alternatives exist? - CORRECT ANSWER Step Therapy
Which of the following is an example of prospective utilization management? - CORRECT
ANSWER Referral Management
, "Medical Necessity" is a factor in coverage determinations when medical good or services
may or may not be covered depending on certain criteria. - CORRECT
ANSWER TRUE
Which of the following can be used to measure utilization? - CORRECT
ANSWER Per-member-per-year metrics
Average length of stay
Bed days per 1,000
Which of the following reasons might be used to exclude a type of service based on medical
necessity? - CORRECT ANSWER Both A&B
Which of the following is a is recognized as an accreditation organization for payers and
managed care organizations? - CORRECT ANSWER -National Committee for Quality
Assurance (NCQA)
-URAC (Utilization Review Accreditation Commission)
-Accreditation Association for Ambulatory Health Care (AAAHC)
Which of the following is an example of a measure used by an accrediting program? -
CORRECT ANSWER -network adequacy
-provider credentialing
-the Consumer Assessment of Health Providers & Systems (CAHPS) survey
The Donabedian model classifies quality activities into which three broad and interrelated
categories? - CORRECT ANSWER Structure, process, outcome
Outcome measures focus on the context in which care and services are provided (not how the
care is provided or the result of that care) - CORRECT ANSWER FALSE
Which of the following is one of the Institute of Medicine (IOM) six goals for providing
quality health care? - CORRECT ANSWER Equitable
