Most Up-to-date Medical Management AHM-540 Free Dumps

NEW QUESTION 1
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
Each quality standard used by a health plan is associated with quality indicators. A ______ indicator is a form of aggregate data indicator that produces results that fit within a specified range, such as the length of time to schedule an appointment.

• A. yes/no
• B. sentinel event
• C. discrete variable
• D. continuous variable

Answer: D

NEW QUESTION 2
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

• A. coordinated outreach model program
• B. case management model program
• C. hub-and-spoke model program
• D. group clinic model program

Answer: B

NEW QUESTION 3
The following statements are about the use of hospitalists to manage inpatient care. Select the answer choice containing the correct statement.

• A. A patient who has been transferred to a hospitalist for management of inpatient care usually continues to receive care from the hospitalist after discharge.
• B. Hospitalists are used primarily to manage care for obstetric, pediatric, and oncology patients.
• C. In order to serve as a hospitalist, a physician must have a background in critical care medicine.
• D. Hospitalists typically spend at least one-quarter of their time in a hospital setting.

Answer: D

NEW QUESTION 4
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.

• A. A primary goal of UR is to address practice variations through the application of uniform standards and guidelines.
• B. UR evaluates whether the services recommended by a member’s provider are covered under the benefit plan.
• C. UR recommends the procedures that providers should perform for plan members.
• D. A health plan’s UR program is usually subject to review and approval by the state insurance and/or health departments.

Answer: C

NEW QUESTION 5
A health plan’s choice of structure measures, process measures, and outcome measures to evaluate performance depends in part on the scientific soundness of the measures. One approach that a health plan can use to enhance scientific soundness is stratification, which refers to the

• A. identification and removal of unusual cases, such as patients with contraindications to a particular treatment, from consideration
• B. statistical adjustment of outcome measures to account for differences in the severity of illness or the presence of other medical conditions
• C. specification of a target population for a procedure and the data collection and analysis methods to be used
• D. elimination of variation within a patient population by dividing the population into groups that are at a similar level of risk

Answer: D

NEW QUESTION 6
A health plan's preventive care initiatives may be classified into three main categories: primary prevention, secondary prevention, and tertiary prevention. Secondary prevention refers to activities designed to

• A. develop an appropriate treatment strategy for patients whose conditions require extensive, complex healthcare
• B. educate and motivate members to prevent illness through their lifestyle choices
• C. prevent the occurrence of illness or injury
• D. detect a medical condition in its early stages and prevent or at least delay disease progression and complications

Answer: D

NEW QUESTION 7
Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located at a military installation. Ms. Wilson serves as a primary point of contact between enrollees and the TRICARE system and answers enrollees’ questions about plan options, eligibility, provider selection, and claims. This information indicates that Ms. Wilson serves as a

• A. lead agent
• B. beneficiary services representative
• C. health plan support contractor
• D. primary care manager (PCM)

Answer: B

NEW QUESTION 8
When analyzing and applying HRA results, the Multistate Health Plan noted sampling bias. This information indicates that the HRA results

• A. do not accurately depict the characteristics of the Multistate member population under study because of errors in data collection
• B. are more accurate for individual Multistate members than they are for the total population
• C. cannot be stated in numerical terms
• D. indicate variation in the number, types, and severity of behavioral risks presented by Multistate’s members

Answer: A

NEW QUESTION 9
The Garnet Health Plan uses provider profiling to measure and improve provider performance. Provider profiling most likely allows Garnet to

• A. evaluate all providers without considering differences in risk
• B. focus on specific clinical decisions of Garnet’s providers rather than on patterns of care
• C. identify the outliers and high-value providers in its provider network
• D. measure the effectiveness, but not the efficiency, of Garnet’s providers

Answer: C

NEW QUESTION 10
One way that health plans evaluate their UR programs is by monitoring utilization rates. By definition, utilization rates typically

• A. indicate changes in the total amount of medical expenses or claim dollars paid for particular procedures
• B. measure the number of services provided per 1,000 members per year
• C. indicate standard approaches to care for many common, uncomplicated healthcare services
• D. report the number of times that a particular provider performs or recommends a service excluded from the benefit plan

Answer: B

NEW QUESTION 11
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.

• A. True
• B. False

Answer: B

NEW QUESTION 12
CMS has developed two prototype programs—Programs of All-inclusive Care for the Elderly (PACE) and the Social Health Maintenance Organization (SHMO) demonstration project—to deliver healthcare services to Medicare beneficiaries. From the answer choices below, select the response that correctly identifies the features of these programs.

• A. PACE-annual limits on benefits for nursing home and community-based care SHMO-no limits on long-term care benefits
• B. PACE-provide long-term care only SHMO-provide acute and long-term care
• C. PACE-enrollees must be age 65 or older SHMO-enrollees must be age 55 or older
• D. PACE-enrollment open to nursing home certifiable Medicare beneficiaries only SHMO- enrollment open to all Medicare beneficiaries

Answer: D

NEW QUESTION 13
The following statement(s) can correctly be made about the characteristics of peer review:
* 1.Peer review is applicable to either single episodes of care or to entire programs of care
* 2.Most peer review is conducted concurrently
* 3.Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services furnished to Medicare and Medicaid recipients enrolled in health plans

• A. All of the above
• B. 1 and 2 only
• C. 1 and 3 only
• D. 2 and 3 only

Answer: C

NEW QUESTION 14
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 up-to-date on immunizations by seven percent within one year.
• C. The QM program director will evaluate the level of provider compliance with clinicalpractice guidelines (CPGs).
• D. The disease management program director will increase participation by asthmatic children in the health plan’s pediatric asthma disease management program.

Answer: B

NEW QUESTION 15
Health plan performance measures include structure measures, process measures, and outcome measures. The following statements are about the characteristics of these three types ofperformance measures. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. The most widely used structure measures relate to physician education and training.
• B. One advantage of structure measures over process measures is that structures are often linked directly to healthcare outcomes.
• C. Process measures are useful in identifying underuse, overuse, and inappropriate use of services.
• D. One disadvantage of outcome measures is that they can be influenced by factors outside the control of the health plan.

Answer: B

NEW QUESTION 16
One difference between outcomes research and clinical research is that outcomes research

• A. provides an absolute measure of treatment results, whereas clinical research provides a relative measure of results
• B. focuses on treatment effectiveness, whereas clinical research focuses on treatmentefficacy
• C. examines diseases and treatments in isolation, whereas clinical research considers the effects of changes in health status and quality of life
• D. gathers outcomes data from controlled clinical trials, whereas clinical research collects and analyzes clinical, financial, and administrative data

Answer: B

NEW QUESTION 17
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.

• A. Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area.
• B. Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day.
• C. Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility.
• D. Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.

Answer: A

NEW QUESTION 18
To facilitate electronic commerce (eCommerce), a health plan may establish a secured extranet. One true statement about a secured extranet is that it is

• A. based on Web-based technologies
• B. available only to the employees of the health plan
• C. publicly available, so the potential exists for unauthorized access to a health plan’s proprietary systems
• D. used to handle the majority of health plan eCommerce

Answer: A

NEW QUESTION 19
For this question, if answer choices (a) through (c) are all correct, select answer choice (d). Otherwise, select the one correct answer choice.
Well-crafted clinical practice guidelines (CPGs) can benefit healthcare delivery processes and outcomes by

• A. providing a framework for care while also allowing for patient-specific variations, based on physician judgment
• B. serving as a basis for evaluating whether providers are practicing in accordance with accepted standards
• C. focusing on the prevention or early detection of a particular condition
• D. all of the above

Answer: D

NEW QUESTION 20
Examples of alternative healthcare practitioners are chiropractors, naturopaths, and acupuncturists. The only well-established credentialing standards for alternative healthcare practitioners are those available from NCQA. These NCQA credentialing standards apply to

• A. chiropractors
• B. naturopaths
• C. acupuncturists
• D. all of the above

Answer: A

NEW QUESTION 21
......