Exam 2

Front 1

True or false? Process measures of health care performancefocus on the context in which care and services are provided.

Back 1

False

Front 2

True or false? Practice guidelines that can be repeated over and over again with the same result are always considered to be valid. A. True

Back 2

False

Front 3

True or false? Report cards are used to assess patterns of an individual provider's care.

Back 3

False

Front 4

True or false? All managed care plans are required by the federal government to participate in accreditation and performance measurement programs.

Back 4

False

Front 5

True or false? All accredited health plans are required to report on their clinical performance though HEDIS.

Back 5

False

Front 6

True or false? A majority of U.S. employers' health benefits plans are effective on January 1 of the subsequent year.

Back 6

True

Front 7

True or false? Payers directly bill the employees in a group medical plan.

Back 7

False

Front 8

True or false? Employers can restrict enrollment in their group plan to full-time employees only.

Back 8

True

Front 9

True or false? Medicare is provided without cost to the Medicare beneficiary.

Back 9

False

Front 10

True or false? The various election periods for Medicare Advantage include:

Back 10

True

Front 11

True or false? Two significant developments that have direct impact on the claims capability include the transition from ICD 9 to ICD 10 diagnosis and procedure codes and the Patient Protection and Affordable Care Act of 2010.

Back 11

True

Front 12

True or false? Benefit determination is the process of automatically determining eligibility and correctly applying benefits and payment terms for each claim using pre-determined rules without any human intervention.

Back 12

False

Front 13

True or false? A participating provider is permitted to balance bill a member for any copayments, coinsurance, or deductibles that are applicable to a claim payment.

Back 13

True

Front 14

True or false? A participating provider is permitted to balance bill a member for any amount not paid due to the application of a fee schedule or other provider payment mechanism.

Back 14

False

Front 15

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

Back 15

False

Front 16

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

Back 16

True

Front 17

True or false? UM focuses on telling doctors and hospitals what to do.

Back 17

False

Front 18

True or false? Hospital utilization varies by geographical area.

Back 18

True

Front 19

True or false? The Affordable Care Act will reduce enrollee cost sharing during the drug coverage gap.

Back 19

True

Front 20

True or false? The Affordable Care Act will phase in plan payment changes to bring payments closer to average FFS amounts.

Back 20

True

Front 21

True or false? CMS requires MA plans to have a quality improvement program to measure program performance.

Back 21

True

Front 22

True or false? The most common reason cited by physicians for limiting their practice to Medicaid consumers was low reimbursement rates.

Back 22

True

Front 23

The first step in developing a quality management program is to:

Back 23

C. Understand consumer need.

Front 24

A set of causes and conditions that come together in a series of steps to transfer inputs into outcomes is called:

Back 24

B. Structure.

Front 25

Which of the following organizations have developed accreditation programs for managed care organizations?

Back 25

E. All of the above. (NCQA, URAC, AAAHC)

Front 26

The Healthcare Effectiveness Data and Information Set (HEDIS) is a measurement tool used by approximately ___ of all health plans.

Back 26

A. 90%.

Front 27

To earn NCQA accreditation, an organization must meet rigorous ___ standards designed to ensure that this key health plan function promotes good medicine rather than acting as an arbitrary barrier to care.

Back 27

B. Utilization management.

Front 28

The following entities must document quality improvement processes in order to gain URAC accreditation.

Back 28

E. All of the above.(A. Credentials verification organizations. B. Health plans. C. Health Web sites.)

Front 29

___ are the intermediary typically focused on smaller employers and are compensated based on commissions paid by the health plan.

Back 29

A. Brokers.

Front 30

Beginning in 2014, what new distribution channel will become available?

Back 30

B. State health insurance exchanges.

Front 31

Traditional health plan customer segments include:

Back 31

C. Both A and B.

(A. Individual, small group, mid-market, large case. B. Medicare and Medicaid.)

Front 32

Which of the following is not considered a "life event"?

Back 32

D. Changing employment.

Front 33

Beginning in 2014, which of the following organizations will be able to enroll individuals into a health plan?

Back 33

C. State health insurance exchanges.

Front 34

Today's transactional processing systems auto adjudicate on average what percentage of claims that are accepted into the processing system.

Back 34

D. 75%

Front 35

Subrogation is defined as:

Back 35

B. The right to recover any damages the member may receive from a third party who assumes responsibility for an accidental injury.

Front 36

Which of the following aspects of the claims capability must be "counted" or measured in order to allocate adequate resources and verify financial assumptions about an insured population?

Back 36

F. All of the above.(A. Inventory receipts. B. Timely filing limits. C. Turnaround time based on the date the MCO received the claim. D. Claims lag. E. IBNR.)

Front 37

___ involves gathering information about applicants or groups of applicants to determine an adequate, competitive, and equitable rate at which to insure them.

Back 37

B. Underwriting.

Front 38

___ involves calculating the premium to be charged for a specific individual or group on the basis of information gathered during the ___ process.

Back 38

A. Rating, Underwriting.

Front 39

The best data source for any health plan is ___ because it implicitly recognizes all the plan-specific characteristics.

Back 39

C. Experience.

Front 40

___ rates are high enough to generate sufficient revenue to cover all claims and other plan expenses and to yield an acceptable return on equity.

Back 40

B. Adequate.

Front 41

___ rates will approximate any given group's costs without an unreasonable amount of cross-subsidization across groups.

Back 41

A. Equitable.

Front 42

The rate formula typically adjusts the base rate for all of the following factors except:

Back 42

C. Eating habits.

Front 43

___ is the term for the rate at which medical services are used.

Back 43

B. Utilization.

Front 44

Which type of MA plan is experiencing an increase in availability and enrollment due to broad waivers from CMS?

Back 44

D. Group retiree plan.

Front 45

Dual Eligible Special Needs Plans enroll individuals who are "dual eligible." Who are the "dual eligible"? A. Individuals who are eligible for Medicare and have Long-Term care insurance. B. Individuals who are eligible for Medicare and Medicaid.

Back 45

B. Individuals who are eligible for Medicare and Medicaid.

Front 46

Which of the following is most likely to cause the rise of Medicare enrollment in MA plans over the next few decades?

Back 46

B. Baby Boomer interest in staying in managed care when becoming eligible for Medicare.

Front 47

Which of the following represents the largest group of individuals in the Medicaid program?

Back 47

A. Persons who are low income with dependents.

Front 48

Which of the following groups represent the largest expenditures for the Medicaid program?

Back 48

D. Persons receiving long term care in nursing homes.

Front 49

What safety net providers were developed in the last 40 years to bridge and close the access gap for Medicaid beneficiaries?

Back 49

D. All of the above.(A. FQHCs. B. RHCs. C. Community clinics, mental health clinics and outpatient clinics.)

Front 50

Which of the following is not in effect for all health benefits plans before 2014?

Back 50

B. Immediate elimination of annual maximum benefits.