MANAGED CARE EXAM 3 questions well
answered 100% passed
the right of payer to recover any legal settlement or award dollars associated with healthcare
costs if a member was harmed by a third party. - correct answer ✔✔Subrogation
Under _________, people who lose their employer-based group coverage due to a life event are
usually able to extend that coverage for up to 18 months (or 36 months in some cases). - correct
answer ✔✔COBRA
Employers are not compelled to offer group health benefits, so employment by itself does not
necessarily mean an employee will have health insurance. However, the ACA created penalties
for employers with more than 25 employees if they do not offer coverage, although these
penalty costs are generally lower than care coverage costs. - correct answer ✔✔Employer
Mandates
the period in which individuals can join or change health plans, as defined in the ACA and
applicable to the mandated open enrollment requirements that began in 2014. - correct answer
✔✔Enrollment Period
Healthcare marketplaces in which people can purchase health insurance, each state has to
create its own healthcare exchange and if they can then the federal government will step in to
help them set it up. - correct answer ✔✔healthcare exchanges
A payer's ___ system refers to the computer hardware, software, and telecommunications
systems and supports the organization uses to collect, store, transmit, operationally use, and
analyze data and information, and communicate via voice and electronic data interchange. -
correct answer ✔✔IT
,Administrative services are often seen as the "________" and viewed as adding little value.
During the 1990's it was a negative association. - correct answer ✔✔Middlemen
________ refers to the various activities that support the sales effort and the plan in the
marketplace, but it usually does not include actual sales. - correct answer ✔✔Marketing
_________ refer to the processes of actually selling products and services that the health plan
offers. - correct answer ✔✔Sales
What are the three basic categories of Utilization Management:
- HMO, PPO, IPA
- Coinsurance, Deductible, Premium
- Prospective, Concurrent, Retrospective
- Structure, Process, Outcome - correct answer ✔✔Prospective, Concurrent, Retrospective
IOMs six goals to quality management include:
-safe, effective, patient-centered, timely, efficient, equitable
-IOM does not have any goals for quality management
-productivity, safe, employer-centered, fast-paced, equality, friendly
-structure, process, outcome, provider-centered, effective, timely - correct answer ✔✔-safe,
effective, patient-centered, timely, efficient, equitable
Donabedian's classic model of Quality Management is comprised of:
-Precision, Communication, Organization
,-Structure, Process, Outcome
-Teamwork, Focus, Structure
-Education, Loyalty, Communication - correct answer ✔✔-Structure, Process, Outcome
Accreditation is driven by all of these EXCEPT:
-Employer mandates
-Federal Government requirements only
-Consumers use of data and information
-Desire by health plans to demonstrate quality objectively as market distinction - correct
answer ✔✔Federal Government requirements only
Under Utilization Management the two components of Retrospective are:
-case review, pattern analysis
-case review, demand management
-pattern analysis, case analysis
-referral management, case analysis - correct answer ✔✔case review, pattern analysis
Concurrent services:
-reviews individual case
-are issued before any services is rendered
-applies to urgent admissions
-applies to elective services - correct answer ✔✔applies to urgent admissions
, Which of the following is NOT an example of a typical coverage exclusion based on medical
necessity?
-Services that are primarily for the convenience of the patient or physician
-Custodial care or care that is essentially assistance with acts of daily living
-Services that are less costly than an alternative service or sequence of services at least as likely
to produce equivalent results
-Experimental or investigational care, except in defined circumstances - correct answer
✔✔Services that are less costly than an alternative service or sequence of services at least as
likely to produce equivalent results
Which of the following is accreditation NOT driven by?
-Desire by health plans to demonstrate quality objectively as market distinction
-The National Committee for Quality Assurance (NCQA)
-Employers mandates
-State and federal government requirements
-Consumers use of data and information - correct answer ✔✔The National Committee for
Quality Assurance (NCQA)
Which is NOT a primary managed care accreditation organization?
-National Committee for Quality Assurance
-URAC
-JCAHO
-Accreditation Association for Ambulatory Health Care - correct answer ✔✔JCAHO
All of the following are under Utilization Management EXCEPT:
answered 100% passed
the right of payer to recover any legal settlement or award dollars associated with healthcare
costs if a member was harmed by a third party. - correct answer ✔✔Subrogation
Under _________, people who lose their employer-based group coverage due to a life event are
usually able to extend that coverage for up to 18 months (or 36 months in some cases). - correct
answer ✔✔COBRA
Employers are not compelled to offer group health benefits, so employment by itself does not
necessarily mean an employee will have health insurance. However, the ACA created penalties
for employers with more than 25 employees if they do not offer coverage, although these
penalty costs are generally lower than care coverage costs. - correct answer ✔✔Employer
Mandates
the period in which individuals can join or change health plans, as defined in the ACA and
applicable to the mandated open enrollment requirements that began in 2014. - correct answer
✔✔Enrollment Period
Healthcare marketplaces in which people can purchase health insurance, each state has to
create its own healthcare exchange and if they can then the federal government will step in to
help them set it up. - correct answer ✔✔healthcare exchanges
A payer's ___ system refers to the computer hardware, software, and telecommunications
systems and supports the organization uses to collect, store, transmit, operationally use, and
analyze data and information, and communicate via voice and electronic data interchange. -
correct answer ✔✔IT
,Administrative services are often seen as the "________" and viewed as adding little value.
During the 1990's it was a negative association. - correct answer ✔✔Middlemen
________ refers to the various activities that support the sales effort and the plan in the
marketplace, but it usually does not include actual sales. - correct answer ✔✔Marketing
_________ refer to the processes of actually selling products and services that the health plan
offers. - correct answer ✔✔Sales
What are the three basic categories of Utilization Management:
- HMO, PPO, IPA
- Coinsurance, Deductible, Premium
- Prospective, Concurrent, Retrospective
- Structure, Process, Outcome - correct answer ✔✔Prospective, Concurrent, Retrospective
IOMs six goals to quality management include:
-safe, effective, patient-centered, timely, efficient, equitable
-IOM does not have any goals for quality management
-productivity, safe, employer-centered, fast-paced, equality, friendly
-structure, process, outcome, provider-centered, effective, timely - correct answer ✔✔-safe,
effective, patient-centered, timely, efficient, equitable
Donabedian's classic model of Quality Management is comprised of:
-Precision, Communication, Organization
,-Structure, Process, Outcome
-Teamwork, Focus, Structure
-Education, Loyalty, Communication - correct answer ✔✔-Structure, Process, Outcome
Accreditation is driven by all of these EXCEPT:
-Employer mandates
-Federal Government requirements only
-Consumers use of data and information
-Desire by health plans to demonstrate quality objectively as market distinction - correct
answer ✔✔Federal Government requirements only
Under Utilization Management the two components of Retrospective are:
-case review, pattern analysis
-case review, demand management
-pattern analysis, case analysis
-referral management, case analysis - correct answer ✔✔case review, pattern analysis
Concurrent services:
-reviews individual case
-are issued before any services is rendered
-applies to urgent admissions
-applies to elective services - correct answer ✔✔applies to urgent admissions
, Which of the following is NOT an example of a typical coverage exclusion based on medical
necessity?
-Services that are primarily for the convenience of the patient or physician
-Custodial care or care that is essentially assistance with acts of daily living
-Services that are less costly than an alternative service or sequence of services at least as likely
to produce equivalent results
-Experimental or investigational care, except in defined circumstances - correct answer
✔✔Services that are less costly than an alternative service or sequence of services at least as
likely to produce equivalent results
Which of the following is accreditation NOT driven by?
-Desire by health plans to demonstrate quality objectively as market distinction
-The National Committee for Quality Assurance (NCQA)
-Employers mandates
-State and federal government requirements
-Consumers use of data and information - correct answer ✔✔The National Committee for
Quality Assurance (NCQA)
Which is NOT a primary managed care accreditation organization?
-National Committee for Quality Assurance
-URAC
-JCAHO
-Accreditation Association for Ambulatory Health Care - correct answer ✔✔JCAHO
All of the following are under Utilization Management EXCEPT:
