AHM-540 Medical Management Questions and Answers

The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through

1. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

2. The National Committee for Quality Assurance (NCQA)

3. The American Accreditation HealthCare Commission/URAC (URAC)

The BBA of 1997 allows states to provide Medicaid benefits to children through the State Children’s Health Insurance Program (SCHIP). Under the terms of the BBA, states can implement SCHIP as

1. Part of their existing Medicaid programs

2. Separate commercial insurance programs

The following statements are about the characteristics of a utilization review (UR) program. 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 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.

Determine whether the following statement is true or false:

With respect to the size of a managed care organization (MCO) and its medical management operations, it is correct to say that large health plans typically have more integration among activities and less specialization of roles than do small MCOs.

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.

If Ms. Stanley agrees to the generic substitution, she will receive a drug that

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.

To facilitate electronic commerce (eCommerce), a health plan may establish a secured extranet. One true statement about a secured extranet is that it is

Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide should Mr. Farrell become incapacitated.

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.

Decisions regarding Mr. Farrell’s end-of-life care are legally the right and responsibility of

The following statement(s) can correctly be made about the scope of case management:

1. Case management incorporates activities that may fall outside a health plan’s typical responsibilities, such as assessing a member’s financial situation

2. Case management generally requires a less comprehensive and complex approach to a course of care than does utilization review

3. Case management is currently applicable only to medical conditions that require inpatient hospital care and are categorized as catastrophic in terms of health and/or costs

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.

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.

The QAPI (Quality Assessment Performance Improvement Program) is a Centers for Medicaid and Medicare Services (CMS) initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standards apply to

The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self-care most likely would not be appropriate.

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

TRICARE enrollees have the right to challenge authorization and coverage decisions. Such challenges are referred to as (appeals / grievances) and are typically handled by the (TRICARE contractor / Area Field Office).

The case management program director at the Nova Health Plan calculated the program’s ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:

Administrative costs for case management ..........$40,000

Actual medical care expenses for patients under case management ..........$680,000

Projected medical care expenses for the same patients without case management ..........$900,000

This information indicates that, for the previous quarter, Nova’s ratio of medical expense savings to case management administrative costs was

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

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

Determine whether the following statement is true or false:

The key to successfully managing the quality and cost-effectiveness of healthcare services for Medicaid enrollees is to merge Medicaid recipients into existing plans.

The following statements are about medical management considerations for dental care. Select the answer choice containing the correct statement.

The following statements are about risk management for case management. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

Medicare beneficiaries can obtain healthcare benefits through fee-for-service (FFS) Medicare programs, Medicare medical savings account (MSA) plans, Medigap insurance, or coordinated care plans (CCPs). Unlike other coverage options, CCPs