Managed Care Test 3 UPDATED QUESTIONS
AND CORRECT ANSWERS
What does preventative healthcare span? - CORRECT ANSWER - Immunizations, pap
smears, mammograms, and screenings for high cholesterol, high blood pressure, diabetes, and
other common chronic diseases
- wellness programs
What does prevention target? - CORRECT ANSWER "Preventing certain disease and
conditions"
healthcare that is aimed at preventing complications of existing diseases and the occurrence
of disease
What is the most common form of prevention? - CORRECT ANSWER Child
immunizations
What types of programs or services are targeted by wellness programs? - CORRECT
ANSWER - helping members to change their lifestyles and develop healthy habits
- example: weight loss, smoking cessation, and exercise program
What are HRAs (Health Risk Assessment) - CORRECT ANSWER Self-administered
assessment tool used to quickly make an overall assessment tool used to quickly make and
overall assessment of new patients medical condition and risk factors
Understand how to measure the various types of utilization and understand what groups it
targets - CORRECT ANSWER - total membership in the month
- total number of outpatient procedures in the month
- average cost of outpatient procedures in the month
What is the common measurement of inpatient utilization? - CORRECT
ANSWER bed-days per thousand enrollees
, What are the alternatives to acute care hospitalization - CORRECT ANSWER subacute
care, step-down units, outpatient facilities, home care, hospice care
what is the difference between coverage decisions and medical care decision? - CORRECT
ANSWER medical care decisions are made by a doctor and a patient.
Coverage decisions are made by managed healthcare plans
what is medical necessity? - CORRECT ANSWER a factor in coverage determinations
when medical goods or services may or may not be covered depending on criteria
-- typically not a factor for routine services (PCP)
example of the types of services that may be EXCLUDED for medical necessity include: -
CORRECT ANSWER -Services that are primarily for the convenience of the patient or
physician
- services that are more costly than an alternative or sequence of services at least as likely to
produce equivalent results
- custodial care or care that is essential assistance with acts of daily living
- experimental or investigational care (except in defined circumstances)
- Not medically appropriate by generally accepted standards of medical practice
what are evidence based clinical criteria and guidelines based on? - CORRECT
ANSWER Formal medical studies and clinical trials
basic utilization management refers to - CORRECT ANSWER the routine functions
used to manage the cost of the most widely medical services
AND CORRECT ANSWERS
What does preventative healthcare span? - CORRECT ANSWER - Immunizations, pap
smears, mammograms, and screenings for high cholesterol, high blood pressure, diabetes, and
other common chronic diseases
- wellness programs
What does prevention target? - CORRECT ANSWER "Preventing certain disease and
conditions"
healthcare that is aimed at preventing complications of existing diseases and the occurrence
of disease
What is the most common form of prevention? - CORRECT ANSWER Child
immunizations
What types of programs or services are targeted by wellness programs? - CORRECT
ANSWER - helping members to change their lifestyles and develop healthy habits
- example: weight loss, smoking cessation, and exercise program
What are HRAs (Health Risk Assessment) - CORRECT ANSWER Self-administered
assessment tool used to quickly make an overall assessment tool used to quickly make and
overall assessment of new patients medical condition and risk factors
Understand how to measure the various types of utilization and understand what groups it
targets - CORRECT ANSWER - total membership in the month
- total number of outpatient procedures in the month
- average cost of outpatient procedures in the month
What is the common measurement of inpatient utilization? - CORRECT
ANSWER bed-days per thousand enrollees
, What are the alternatives to acute care hospitalization - CORRECT ANSWER subacute
care, step-down units, outpatient facilities, home care, hospice care
what is the difference between coverage decisions and medical care decision? - CORRECT
ANSWER medical care decisions are made by a doctor and a patient.
Coverage decisions are made by managed healthcare plans
what is medical necessity? - CORRECT ANSWER a factor in coverage determinations
when medical goods or services may or may not be covered depending on criteria
-- typically not a factor for routine services (PCP)
example of the types of services that may be EXCLUDED for medical necessity include: -
CORRECT ANSWER -Services that are primarily for the convenience of the patient or
physician
- services that are more costly than an alternative or sequence of services at least as likely to
produce equivalent results
- custodial care or care that is essential assistance with acts of daily living
- experimental or investigational care (except in defined circumstances)
- Not medically appropriate by generally accepted standards of medical practice
what are evidence based clinical criteria and guidelines based on? - CORRECT
ANSWER Formal medical studies and clinical trials
basic utilization management refers to - CORRECT ANSWER the routine functions
used to manage the cost of the most widely medical services
