Which option is NOT true regarding prospective UM techniques?
A) It requires an opinion from a practitioner other than the specialist making the
recommendation to confirm that a proposed treatment is appropriate
B) The primary care physician (PCP) coordinates, manages, and authorizes al services
for the patient
C) It is an analysis of practice patterns intended to target individual case reviews and
identify potential problems
D) It requires a resolution that the proposed medical service is appropriate for the
patient - CORRECT ANSWER C) It is an analysis of practice patterns intended to target
individual case reviews and identify potential problems
Although it now offers accreditation for a spectrum of healthcare services, URAC
originally offered a specialty accreditation program for _________:
A) Disease management
B) Health plans
C) Core standards addressing organizational functions for healthcare
D) Utilization management - CORRECT ANSWER D) Utilization management
Determining whether an inpatient or outpatient medical service is appropriate for a
patient is a component of what type of utilization management review?
A) Prospective
B) Concurrent
C) Post Discharge
D) Retrospective - CORRECT ANSWER A) Prospective
Accountable Care Organizations are designed with the following criteria:
A) To save money by avoiding unnecessary services
B) To make providers independent of each other
C) To provide no financial incentives for provider cooperation
D) To increase the use of emergency room services - CORRECT ANSWER A) To save
money by avoiding unnecessary services
,Contract performance modeling is:
A) An initiative used to help increase an organization's reimbursement payments
B) An initiative used to help increase an organization's revenue/ profit/ margins
C) An initiative used to help increase the interest and participation of stakeholders
D) An initiative used to help increase the quality of an organization's services -
CORRECT ANSWER B) An initiative used to help increase an organization's revenue/
profit/ margins
Making advance payment to providers for all services needed to care for a member, in
an effort to control costs is known as:
A) Financial Management
B) Risk Adjustment
C) Capitation
D) Premium - CORRECT ANSWER C) Capitation
Under capitation, which option is NOT an increased risk for the provider:
A) Cost of delivering care
B) Product marketing that could result in adverse selection (or a disproportionate
amount of people who will need care)
C) Cost of retaining quality physicians
D) Accuracy of the actuarial projections used to determine the anticipated use, severity,
and acuity of services to be provided - CORRECT ANSWER D) Accuracy of the
actuarial projections used to determine the anticipated use, severity, and acuity of
services to be provided
Disproportionate/ concentrated expenditures on a relatively small percentage of the
population with chronic condition is a factor:
A) That can clearly be identified as a contributing driver of health cost increases
B) That contributes to the fundamental change in the relationships between healthcare
organizations and the government
C) That can clearly be identified as a reason for healthcare coverage denials
D) That contributes to the fundamental change in the relationships between consumers
and providers - CORRECT ANSWER A) That can clearly be identified as a contributing
driver of health cost increases
, To ensure that MCOs contracting with Medicare and Medicaid protect and improve the
health and satisfaction of enrolled beneficiaries, is the purpose of:
A) The Balance Budget Act of 1997 (BBA)
B) Quality Assurance (QA)
C) Quality Improvement System for Managed Care (QISMC)
D) Medicare Advantage (MA) - CORRECT ANSWER C) Quality Improvement System
for Managed Care (QISMC)
The following are types of Accountable Care Organizations offered by Medicare except:
A) Pioneer ACO Model
B) Medicare Shared Savings Program
C) Advance Payment Model
D) Healthcare Maintenance Organization Model - CORRECT ANSWER D) Healthcare
Maintenance Organization Model
Which option is NOT true concerning URAC:
A) URAC's standards keep pace with the rapid changes in the healthcare system
B) Established in 1990, it is formerly known as the Utilization Review Accreditation
Commission
C) URAC's standards provide a mark of distinction for healthcare organizations to
demonstrate their commitment to quality and accountability
D) Provides a comprehensive assessment covering physician practice management -
CORRECT ANSWER D) Provides a comprehensive assessment covering physician
practice management
Which option is NOT true concerning the Health Maintenance Organization Act of 1973:
A) It represented a significant change in the way the federal government regulated
health policies
B) It was directed at changing the system of healthcare delivery
C) It is the legislation that governs health benefit plans of self-insured, self-funded
employers in the United States
D) It established financial guidelines for operating an HMO - CORRECT ANSWER C) It
is the legislation that governs health benefit plans of self-insured, self-funded employers
in the United States
A) It requires an opinion from a practitioner other than the specialist making the
recommendation to confirm that a proposed treatment is appropriate
B) The primary care physician (PCP) coordinates, manages, and authorizes al services
for the patient
C) It is an analysis of practice patterns intended to target individual case reviews and
identify potential problems
D) It requires a resolution that the proposed medical service is appropriate for the
patient - CORRECT ANSWER C) It is an analysis of practice patterns intended to target
individual case reviews and identify potential problems
Although it now offers accreditation for a spectrum of healthcare services, URAC
originally offered a specialty accreditation program for _________:
A) Disease management
B) Health plans
C) Core standards addressing organizational functions for healthcare
D) Utilization management - CORRECT ANSWER D) Utilization management
Determining whether an inpatient or outpatient medical service is appropriate for a
patient is a component of what type of utilization management review?
A) Prospective
B) Concurrent
C) Post Discharge
D) Retrospective - CORRECT ANSWER A) Prospective
Accountable Care Organizations are designed with the following criteria:
A) To save money by avoiding unnecessary services
B) To make providers independent of each other
C) To provide no financial incentives for provider cooperation
D) To increase the use of emergency room services - CORRECT ANSWER A) To save
money by avoiding unnecessary services
,Contract performance modeling is:
A) An initiative used to help increase an organization's reimbursement payments
B) An initiative used to help increase an organization's revenue/ profit/ margins
C) An initiative used to help increase the interest and participation of stakeholders
D) An initiative used to help increase the quality of an organization's services -
CORRECT ANSWER B) An initiative used to help increase an organization's revenue/
profit/ margins
Making advance payment to providers for all services needed to care for a member, in
an effort to control costs is known as:
A) Financial Management
B) Risk Adjustment
C) Capitation
D) Premium - CORRECT ANSWER C) Capitation
Under capitation, which option is NOT an increased risk for the provider:
A) Cost of delivering care
B) Product marketing that could result in adverse selection (or a disproportionate
amount of people who will need care)
C) Cost of retaining quality physicians
D) Accuracy of the actuarial projections used to determine the anticipated use, severity,
and acuity of services to be provided - CORRECT ANSWER D) Accuracy of the
actuarial projections used to determine the anticipated use, severity, and acuity of
services to be provided
Disproportionate/ concentrated expenditures on a relatively small percentage of the
population with chronic condition is a factor:
A) That can clearly be identified as a contributing driver of health cost increases
B) That contributes to the fundamental change in the relationships between healthcare
organizations and the government
C) That can clearly be identified as a reason for healthcare coverage denials
D) That contributes to the fundamental change in the relationships between consumers
and providers - CORRECT ANSWER A) That can clearly be identified as a contributing
driver of health cost increases
, To ensure that MCOs contracting with Medicare and Medicaid protect and improve the
health and satisfaction of enrolled beneficiaries, is the purpose of:
A) The Balance Budget Act of 1997 (BBA)
B) Quality Assurance (QA)
C) Quality Improvement System for Managed Care (QISMC)
D) Medicare Advantage (MA) - CORRECT ANSWER C) Quality Improvement System
for Managed Care (QISMC)
The following are types of Accountable Care Organizations offered by Medicare except:
A) Pioneer ACO Model
B) Medicare Shared Savings Program
C) Advance Payment Model
D) Healthcare Maintenance Organization Model - CORRECT ANSWER D) Healthcare
Maintenance Organization Model
Which option is NOT true concerning URAC:
A) URAC's standards keep pace with the rapid changes in the healthcare system
B) Established in 1990, it is formerly known as the Utilization Review Accreditation
Commission
C) URAC's standards provide a mark of distinction for healthcare organizations to
demonstrate their commitment to quality and accountability
D) Provides a comprehensive assessment covering physician practice management -
CORRECT ANSWER D) Provides a comprehensive assessment covering physician
practice management
Which option is NOT true concerning the Health Maintenance Organization Act of 1973:
A) It represented a significant change in the way the federal government regulated
health policies
B) It was directed at changing the system of healthcare delivery
C) It is the legislation that governs health benefit plans of self-insured, self-funded
employers in the United States
D) It established financial guidelines for operating an HMO - CORRECT ANSWER C) It
is the legislation that governs health benefit plans of self-insured, self-funded employers
in the United States
