The nature of behavioral healthcare creates unique medical management challenges for health plans. One method health plans have used to support the delivery of appropriate services in a cost-effective manner is to
Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.
The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Greenhouse’s prescription drug reimbursement policy indicates that the plan formulary is classified as (open / closed), and that compliance by patients and providers is (mandatory / voluntary).
Selene Varga is participating in her health plan’s disease management program for congestive heart failure. Ms. Varga’s health status is regularly monitored and managed by a licensed nurse who visits Ms. Varga at her home to administer treatment and assess the need for changes in Ms. Varga’s overall care plan. This information indicates that Ms. Varga is participating in the type of disease management program known as a
Determine whether the following statement is true or false:
Independent review organizations (IROs) can mediate disputes and offer advisory opinions to health plans on UR issues, but they cannot render binding decisions on appeals.
The American Accreditation HealthCare Commission/URAC (URAC) has an accreditation program specifically for case management services. From the answer choices below, select the response that correctly identifies the type(s) of case management services addressed by URAC’s standards and the type(s) of organizations to which these standards may be applied.
PBMs are accredited by the same organizations that accredit health plans.
One method of transferring the information in electronic medical records (EMRs) is through a health information network (HIN). The following statements are about HINs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
The paragraph below contains two pairs of terms enclosed in parentheses. Select the term in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms you have chosen.
A primary distinction between skilled care and subacute care relates to the extent and medical complexity of the patient’s needs. Generally, subacute care patients require (more / fewer) services from physicians and nurses and (more / less) extensive rehabilitation services than do skilled care patients.
Recent laws and regulations have established new requirements for Medicaid eligibility. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 affected Medicaid eligibility by
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
Medical management programs often require the analysis of many types of data and information. __________________ is an automated process that analyzes variables to help detect patterns and relationships in the data.
One true statement about state regulation of case management activities is that the majority of states
The following statements are about health plans' complaint resolution procedures (CRPs). Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
One of the steps in drug utilization review (DUR) is defining optimal drug use, which can be accomplished by applying diagnosis criteria and drug-specific criteria. Drug-specific criteria are standards that identify the
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
The Balanced Budget Act (BBA) of 1997 established the use of ___________ to determine coverage of emergency services for Medicare and Medicaid enrollees in health plans.
The Fairview Health Plan uses a dual database approach to integrate information needed for its disease management program. This information indicates that Fairview uses an information management system that
The Riverside Health Plan is considering the following provider compensation options to use in its contracts with several provider groups and hospitals:
1. A discounted fee-for-service (DFFS) payment system
2. A case rate system
3. Capitation
If Riverside wants to use only those compensation methods that encourage the efficient use of resources, then the compensation method(s) that Riverside should consider for its new contracts include
Breanna Osborn is a case manager for a regional health plan. One component of Ms. Osborn’s job is the collection and evaluation of medical, financial, social, and psychosocial information about a member’s situation. This component of Ms. Osborn’s job is known as
Determine whether the following statement is true or false:
Immunization programs are a direct means of reducing health plan members’ needs for healthcare services and are typically cost-effective.
Economically, health plans cannot provide coverage for every drug available from every manufacturer. As a result, purchaser contracts often include provisions specifying that certain drugs or drug types will not be covered. These provisions are referred to as
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.
Determine whether the following statement is true or false:
The delegation of medical management functions to providers can occur without the transfer of financial risk.
Health plans communicate proposed performance changes through action statements. Select the answer choice containing an action statement that includes all of the required elements.
Health plans have a specified number of working days to respond to Level One appeals, as stated by company policy or regulatory requirements. With regard to the timeframes for appeals, it is generally correct to say
1. That the typical timeframe requires a health plan to respond to appeals in fewer than 20 days
2. That the timeframe is accelerated for expedited appeals
3. That the review period begins when the appeal arrives at a health plan
The case management team at the Hightower Health Plan reviewed the medical records of the following two plan members to determine the type of care each one needs and the most appropriate setting for that care:
Ira Morton was hospitalized for a severe stroke. Although his medical condition is stable, the stroke left him partially paralyzed and he will require extensive rehabilitation and 24-hour medical care.
Theresa Finley is recovering from a total hip replacement and is in need of short-term physical therapy and twice-weekly visits from a licensed nurse to check her blood pressure and the healing of her incision.
From the answer choices below, select the response that correctly identifies the level of care that would be most appropriate for Mr. Morton and Ms. Finley.