AHM-540 Online Practice Questions and Answers

In order to achieve changes in outcomes, health plans make changes to existing structures and processes. The introduction of preauthorization as an attempt to control overuse of services is an example of a reactive change. Reactive changes are typically

A. both planned and controlled

B. planned, but they are rarely controlled

C. controlled, but they are rarely planned

D. neither planned nor controlled

Occasionally, employers combine workers' compensation, group healthcare, and disability programs into an integrated product known as 24-hour coverage. One true statement about 24-hour coverage is that it typically

A. increases administrative costs

B. requires plans to maintain separate databases of patient care information

C. exempts plans from complying with state workers' compensation regulations

D. allows plans to apply disability management and return-to-work techniques to nonoccupational conditions

PBMs are accredited by the same organizations that accredit health plans.

A. True

B. False

Outcomes management is a tool that health plans use to maximize all the results associated with healthcare processes. The following statement(s) can correctly be made about outcomes management:

1.The goal of outcomes management is to identify and implement treatments that are cost- effective and deliver the greatest value

2.Outcomes management introduces performance as a critical factor in the assessment and improvement of outcomes

A. Both 1 and 2

B. 1 only

C. 2 only

D. Neither 1 nor 2

This agency's accreditation decisions are based on the results of an on-site survey of clinical and administrative systems and processes, as well as the health plan's performance on selected effectiveness of care and member satisfaction measures.

A. American Accreditation HealthCare Commission/URAC (URAC)

B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

C. Community Health Accreditation Program (CHAP)

D. National Committee for Quality Assurance (NCQA)

Health plans communicate proposed performance changes through action statements. Select the answer choice containing an action statement that includes all of the required elements.

A. The proportion of adult members who are screened for hypertension will increase by ten percent.

B. Primary care providers (PCPs) will increase the proportion of children under the age of two who are upto-date on immunizations by seven percent within one year.

C. The QM program director will evaluate the level of provider compliance with clinical practice guidelines (CPGs).

D. The disease management program director will increase participation by asthmatic children in the health plan's pediatric asthma disease management program.

The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the two terms or phrases that you have selected.

The process for collecting and analyzing data differs for quality assessment (QA) and quality improvement (QI). For QA, data collection focuses on (objective / both objective and subjective) data, and data analysis identifies the (degree / cause) of variance.

A. objective / degree

B. objective / cause

C. both objective and subjective / degree

D. both objective and subjective / cause

The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.

To manage the delivery of healthcare services to their members, health plans use clinical practice parameters. ___________________ is the type of clinical practice parameter that a health plan uses to make coverage decisions concerning medical necessity and appropriateness.

A. A clinical practice guideline (CPG)

B. Medical policy

C. Benefits administration policy

D. A standard of care

All states have laws describing the conditions under which pharmacists can substitute a generic drug for a brand-name drug. With respect to these laws, it is correct to say that in every state,

A. pharmacists must obtain physician approval before substituting generics for brand-name drugs

B. pharmacists must obtain authorization from the health plan before substituting generics for brand-name drugs

C. prescribers must obtain authorization from the health plan before prescribing a brand- name drug

D. prescribers have some mechanism that allows them to prevent pharmacists from substituting generics for brand-name drugs

Many health plans use clinical pathways to help manage the delivery of acute care services to plan members. One true statement about clinical pathways is that they

A. determine which healthcare services are medically necessary and appropriate for a particular patient in a particular situation

B. outline the services that will be delivered, the providers responsible for delivering the services, the timing of delivery, the setting in which services are delivered, and the expected outcomes of the interventions

C. cover only services delivered in an acute inpatient setting

D. address medical conditions that affect a small segment of a given population and with which the majority of providers are unfamiliar