question

Behavioral change tools include all but which of the following? Analytics Termination from the network Mission clarity Communications

answer

Termination from the network

question

Fee-for-service physicians are financially rewarded for good disease management in most environments. T or F

answer

False

question

The Managed care backlash resulted in which of the following? A reduction in HMO membership New federal and state laws and regulations Reduced administrative costs

answer

A reduction in HMO membership New federal and state laws and regulations

question

The HMO Act of 1973 did contributed to the growth of managed care T or F

answer

True

question

Which of the following forms of hospital payment contain no elements of risk sharing by the hospital? DRGs and MS-DRGs Per diem Capitation Sliding scale FFS

answer

Sliding scale FFS

question

PSOs, created by the BBA of 1997, proved to be very popular and successful. T or F

answer

False

question

In January 2006, what large federal prescription drug program was implemented that offered pharmacy benefits to more than 40 million people at that time and is expected to increase by 30% throughout the next decade? The Department of Defense TRICOR program Public Health Service and Indian Health Service State Medicaid programs Medicare Part D

answer

Medicare Part D

question

Managed care is best described as: A broad and constantly changing array of health plans employers, unions, and other purchasers of care that attempt to manage cost, quality, and access to that care A broad changing array of health plans employers, unions, and other purchasers of care. A constantly changing array of unions, and other purchasers of care that attempt to manage cost, quality, and access to that care A array of health plans employers, unions, and other purchasers of care that attempt to manage cost, quality, and access to that care

answer

A broad and constantly changing array of health plans employers, unions, and other purchasers of care that attempt to manage cost, quality, and access to that care

question

Consolidation in the payer industry has resulted in most hospitals being unable to obtain adequate rate increases. T or F

answer

False

question

Which organization(s) need a Corporate Compliance Officer (CCO)? Hospitals Health plans with a Medicare Advantage risk contract Every organization that provides health care

answer

Hospitals and Health plans with a Medicare Advantage risk contract

question

Health Plan Employer Data and Information Set is the less widely used set of measures for reporting on managed behavioral health care. T or F

answer

False

question

The following term refers to an all-inclusive rate paid by the HMO for both institutional and professional services: Bundled payment Per diem Case rate Straight DRGs

answer

Bundled payment

question

The original impetus of HMOs development came from: Providers seeking patient revenues Insurance companies Consumers seeking access to health care A & C Only

answer

Providers seeking patient revenues and Consumers seeking access to health care

question

HMOs are licensed as health insurance companies. True False

answer

false

question

Common sources of information that trigger DM include: Claims Pharmacy data Laboratory tests A & b oNLY

answer

Claims and pharmacy

question

The GPWW requires the participation of a hospital and the formation of a group practice. True False

answer

False

question

An IDS can be described as a legal entity consisting of more than one type of provider to manage a population's health care and/or contract with a payer organization. True False

answer

True

question

Claims review is an example of Concurrent review Discharge planning Prospective review Retrospective review

answer

Retrospective review

question

UM focuses on telling doctors and hospitals what to do. True False

answer

False

question

The same methodology used to pay a hospital for inpatient care is usually also use to pay for outpatient care. True False

answer

False

question

Electronic prescribing offers which of the following potential outcomes? Improvement in physician drug formulary prescribing conformance Reduction in drug interactions and resulting serious adverse effects Reduction in prescribing and dispensing errors All the above

answer

Improvement in physician drug formulary prescribing conformance Reduction in drug interactions and resulting serious adverse effects Reduction in prescribing and dispensing errors

question

Approximately What percentage of behavioral care spending is associated with what percentage of patients? 5% 10% 15% 20%

answer

5%

question

When selecting a hospital during the network development phase, an Health Maintenance Organization considers: Occupancy rate Cost of services Scope of services All the above

answer

Occupancy rate Cost of services Scope of services

question

Most of the care in disease management systems is delivered in the inpatient setting since the acuity is much greater. True False

answer

False

question

State and federal regulations consistently apply network access standards to: POS plans HMOs Preferred Provider Organization A ; B only

answer

POS plans HMOs

question

What specific factors other than diseases commonly affect severity of illness? Culture Geographic location Sex Age All the above

answer

Culture Geographic location Sex Age

question

Which of the following organizations may conduct primary verification of a physician's credentials? A PPO A CVO An HMO All the above

answer

A PPO A CVO An HMO

question

Hospital consolidation has been blocked more often than not by the Department of Justice (DOJ) and/or the Federal Trade Commission (FTC). True False

answer

False

question

Direct contracting refers to direct contracts between the HMO and the physicians. Almost all models of HMOs contract directly with physicians. True False

answer

False

question

1. EPOs share similarities with: PPOs HMOs Point of Service A & B

answer

PPOs HMOs

question

Key common characteristics of PPOs include: Selected provider panels Negotiated payment rates Consumer choice & Utilization management All the above

answer

Selected provider panels Negotiated payment rates Consumer choice & Utilization management

question

All three methods used to manage utilization during the course of a hospitalization. Pre-certification that includes the authorized coverage length of stay Concurrent, or continued stay, review by UM nurses using evidence-based clinical criteria Discharge planning prior to admission or at the beginning of the stay True False

answer

True

question

What are the basic ways to compensate open-panel PCPs? Fee-for-service Capitation DRGs A & B only

answer

Fee-for-service

question

Which of the following is a method for providing a complete picture of care delivered in all health care settings? Inpatient DRGs ICD-9 / ICD-10 codes Health Maintenance Organizations Episodes of care

answer

Episodes of care

question

Costs of noncatastrophic, recurring outpatient care have risen significantly in the past few decades. True False

answer

True

question

What is the common benefit design trend in commercial (employer group sponsored) prescription drug benefits? Increasing copayment amounts, especially for Tier 2 preferred brand drugs and Tier 3 non-preferred brand drugs. Increasing use of percent coinsurance, especially for Tier 3 and Tier 4 specialty tiers when available.. Increasing number of consumer-directed health plan designs with higher front-end deductibles. All the above

answer

Increasing copayment amounts, especially for Tier 2 preferred brand drugs and Tier 3 non-preferred brand drugs. Increasing use of percent coinsurance, especially for Tier 3 and Tier 4 specialty tiers when available.. Increasing number of consumer-directed health plan designs with higher front-end deductibles.

question

Why is data analysis an increasingly important health plan function? Cost increases 2-3 times the consumer price index Potential for improvements in medical management Third-party consultants that specialize in data analysis and aggregate data across health plans All of the above

answer

Cost increases 2-3 times the consumer price index Potential for improvements in medical management Third-party consultants that specialize in data analysis and aggregate data across health plans

question

Nurse-on-call or medical advice programs are considered demand management strategies. True False

answer

True

question

Managed care plans perform onsite reviews of hospitals and ambulatory surgical centers. True False

answer

False

question

Who has final responsibility for all aspects of an independent HMO? Chief Operating Officer (COO) Board of Directors Chief Compliance Officer (CCO) Chief Executive Officer (CEO)

answer

Board of Directors

question

PPOs differ from HMOs because they do not accept capitation risk and enrollees who are willing to pay higher cost sharing may access providers that are not in the contracted network. True False

answer

True

question

The integral components of managed care are Wellness and prevention Primary care orientation Utilization management All of the above

answer

Wellness and prevention Primary care orientation Utilization management

question

The defining feature of a direct contract model is the HMO contracting directly with a hospital to provide acute services to its members. True False

answer

False

question

Board of Directors has final responsibility for all aspects of an independent HMO True False

answer

True

question

Select the one technique for controlling drug benefits costs that MOST health plans and PBMs DO NOT routinely use. Tiered copayments Contracting with pharmacies for discounts Drug formularies Value-based insurance designs that assign "high-value" drugs to Tier 1 for ALL therapeutic categories.

answer

Value-based insurance designs that assign "high-value" drugs to Tier 1 for ALL therapeutic categories.

question

Prior to the 1970s, health maintenance organizations (HMOs) were known as: Point-of-service programs Referred provider organizations Prepaid practices Prepaid group practices

answer

Prepaid group practices

question

Behavioral health care providers are paid under methodologies similar to those applied to medical/surgical care providers. True False

answer

True

question

The function of the board is governance: overseeing and maintaining final responsibility for the plan. Final approval authority of corporate bylaws rests with the board as does setting and approving policy. General oversight of the profitability or reserve status rests with the board, as does oversight and approval of significant fiscal events and quality management. True False

answer

True

question

The Balance Budget Act (BBA) of 1997 resulted in a major increase in HMO enrollment True False

answer

False

question

Electronic clinical support systems are important in disease management. True False

answer

True

question

Hospitals purchased physician practices and employed physicians in the 1990s, but will no longer do so. True False

answer

False

question

The least appropriate site for disease management is: Outreach clinic Ambulatory care setting Short Stay clinic Inpatient setting

answer

Inpatient setting

question

Capitation is usually defined as: Fee-for-service including withhold provisions Stop-loss reinsurance provisions Prepayment for services on a fixed, per member per month basis Performance based compensation system

answer

Prepayment for services on a fixed, per member per month basis

question

Capitation is a physician payment method preferred by many HMOs because it: Costs are predictable Is less costly to administer than FFS Eliminates the FFS incentive to overutilize All the above

answer

Costs are predictable Is less costly to administer than FFS Eliminates the FFS incentive to overutilize

question

The use of utilization guidelines targets only managed care patients and does not have an impact on the care of non-managed care patients. True False

answer

False

question

Managed prescription drug programs must be flexible and customize pharmacy benefit designs to accommodate diverse financial and benefit richness desires of their customers. True False

answer

True

question

More than 90% of members of employer-sponsored health plans have access to prescription drug coverage, and over 90% of all prescriptions in the U.S. are reimbursed by insured prescription drug benefit programs. True False

answer

True

question

In what model does an HMO contract with more than one group practice provide medical services to its members? Group model Staff model Independent Physician Association model Network model

answer

Network model

question

The HMO Act of 1973 did not retard HMO development in the few years after its enactment True False

answer

False

question

Ancillary services are broadly divided into the following categories: Diagnostic and therapeutic Pharmacy and radiology Laboratory and therapeutic A & C only

answer

Diagnostic and therapeutic

question

Medical Directors typically have responsibility for: Utilization management Benefits determinations for appeals Quality management All the above

answer

Utilization management Benefits determinations for appeals Quality management

question

Hospital utilization varies by geographical area. True False

answer

True

question

Recent legislation encourages separate lifetime limits for behavioral care. True False

answer

False

question

A PHO is usually a separate business entity requiring the participation of a hospital and at least some of the hospital's admitting physicians. True False

answer

True

question

One potential negative consequence of drug formularies with high copayments is: Decreased use of the most cost-effective medications Low copayments may be a barrier to adherence Increased use of brand drugs High copayments may be a barrier to adherence

answer

High copayments may be a barrier to adherence

question

In markets with high levels of managed care penetration, hospitals are usually paid using a sliding scale discount on charges method. True False

answer

False

question

Establishing a high level of evidence regarding disease management guidelines ensures: Validity Statistical significanc None of the above Reliability

answer

Validity

question

Two desirable outcomes of tiered prescription member copayments are: Pharmacy gross profits rise and physicians are paid a formulary incentive Member costs increase and brand name drug use will double Brand drug use increases and generic drug use declines The use of less expensive generic drugs increases and members save money by paying lower Tier 1 generic copayments

answer

The use of less expensive generic drugs increases and members save money by paying lower Tier 1 generic copayments

question

Fee-for-service payment is the most common method used by HMOs to pay specialists. True False

answer

True

question

It is possible for a specialist to also act as a primary care provider. True False

answer

True

question

The majority of prescriptions for behavioral health medications are written by nonpsychiatrists. True False

answer

True

question

Basic elements of credentialing include: Hospital privileges Malpractice history Medical license Board Exams All the above

answer

Hospital privileges Malpractice history Medical license Board Exams

question

Payment to a facility for outpatient procedures may be increased on a case-by-case basis through which of the following? Outlier CoPays Carve-outs A and B

answer

Carve-outs

question

Academic detailing refers to: Requiring inadequate physicians to write out, in detail, what they should be doing Having medical school professors present detailed studies at CME conferences Minutely scrubbing the data Personal meetings between a respected clinician and a doctor or a small group of doctors

answer

Personal meetings between a respected clinician and a doctor or a small group of doctors

question

Pay for performance (P4P) cannot be applied to behavioral health care providers. True False

answer

False

question

The typical practicing physician has a good understanding of what is happening with his or her patient between office visits True False

answer

False

question

All of the following are alternatives to acute care hospitalization. ? Subacute care ? Step-down units ? Outpatient facilities/units ? Home care ? Hospice care True False

answer

True

question

Commonly recognized HMOs include: IPAs Network Staff and group All the above

answer

IPAs

question

Blue Cross began as a physician service bureau in the 1930s. True False

answer

False

question

Health care cost inflation has remained consistent since 1995. True False

answer

False

question

In the medical management area, committees serve to diffuse some elements of responsibility and allow important input from the field into procedure and policy or even into case-specific interpretation of existing policy. True False

answer

True

question

An IPA is an HMO that contracts directly with physicians and hospitals True False

answer

False

question

Utilization management seeks to reduce practice variation while promoting good outcomes and ___. Maintaining costs Increasing patients Reducing access None of the above

answer

None of the above

question

Outbound calls to physicians are an important aspect to most DM programs. True False

answer

False

question

The most common measurement of inpatient utilization is: Enrollees per thousand bed days Admissions per thousand bed days Encounters per thousand enrollees Bed days per thousand enrollees

answer

Bed days per thousand enrollees

question

How are outlier cases determined by a hospital? Through cost-accounting Through a Resource Based Relative Value Scale Through the chargemaster All the above

answer

Through the chargemaster

question

Which organization(s) accredit managed behavioral health care companies? National Committee for Quality Assurance The Joint Commission Utilization Review Accreditation Commission Councile of Accreditaion All the above

answer

National Committee for Quality Assurance The Joint Commission Utilization Review Accreditation Commission Councile of Accreditaion

question

Considerations for successful network development include geographic accessibility and hospital-related needs. True False

answer

True

question

What technique is used by many pharmaceutical companies with health plans and PBMs to increase formulary access and utilization of specific products? Rebates for preferred formulary position Health economic data, including a growing number of head-to-head clinical trials Member copayment coupons to offset copayment All the above

answer

Rebates for preferred formulary position Health economic data, including a growing number of head-to-head clinical trials Member copayment coupons to offset copayment

question

What statement is true regarding the trends of traditional, non-specialty drugs (mostly oral and topical drugs dispensed in community pharmacy) and specialty drugs (biotech, injectables, high-cost orals)? Most plans do not cover specialty drugs, except under the medical benefit,and specialty products, therefore, are of no serious cost consequence to pharmacy benefits. The number of generic drugs is declining due to lower manufacture costs and, as a result, traditional (non-specialty) drug products remain the focus of most of the pharmacy budget increases. Traditional drug costs are rising rapidly due to continued launch of new, expensive brand drugs, with only a few approved genericas. The specialty market cost trend is declining as a result of biosimilar "generic" injectable products imported from Europe. Many expensive and popular traditional drugs are losing patent protection, and generics are driving a declining cost trend. A growing number of the drugs in the pipeline for FDA approval are injectable products and the specialty drug trend, already at 20%, is expected to increase. The cost trends and utilization rates of both types of drugs are increasing by 20% per year or more, although specialty drugs are plateauing.

answer

Many expensive and popular traditional drugs are losing patent protection, and generics are driving a declining cost trend. A growing number of the drugs in the pipeline for FDA approval are injectable products and the specialty drug trend, already at 20%, is expected to increase.

question

Advantages of an IPA include: Broader physician choice for members More convenient geographic access Requires less start-up capital All the above

answer

Broader physician choice for members

HOM 5307 – Flashcard

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