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
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Ways that workers’ compensation health plans can help control the costs of job-related injuries and illnesses include
This agency oversees fraud and abuse matters as they relate to medical management.
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.
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
Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the
The following statements are about QAPI as it applies to Medicare+Choice plans and Medicaid health plan entities. Select the answer choice containing the correct statement.
One way that health plans evaluate their UR programs is by monitoring utilization rates. By definition, utilization rates typically
The following statement(s) can correctly be made about performance measurement systems:
1. The most difficult purpose for a performance measurement system to address is to measure changes in outcomes caused by modifications in administrative or clinical treatment processes
2. A health plan needs different performance measurement systems to evaluate its administrative services and the clinical performance of its providers
Some health plans administer a questionnaire known as the Behavioral Risk Factor Surveillance System (BRFSS) as part of their health risk assessment (HRA) processes. The following statements are about the BRFSS. If statements (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct statement.
TESTED 23 Feb 2025
