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116 Cards in this Set
- Front
- Back
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Practice guidelines that can be applied across settings and providers?
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Reliable
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The first step in in developing a quality management program is to:
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Understand consumer need
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A set of causes and conditions that come together in a series of steps to transfer inputs into outcomes is called?
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Structure
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The Institute of Medicine’s Committee on the Quality of Health Care in America proposed six aims for improvement in our health care system. Name the six aims and provide examples of each:
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Safe
Effective Patient-centered Timely Efficient Equitable |
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List Donabedian’s three criteria for quality assessment.
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Structure
Process Outcome |
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What additions can be made to Donabedian’s three criteria for quality assessment for further improvement?
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Systems thinking that considers interrelated processes.
Customer focus Use of knowledge and measurement tools to inform improvement |
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Describe the key steps in developing a modern quality management program.
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•Understand customer need
•Identify processes and outcomes that meet customer needs •Identify and study best-of-class organizations •Define indicators to measure performance •Establish performance expectations •Monitor performance and evaluate in terms of expectations |
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True or false? Process measures of health care performance focus on the context in which care and services are provided.
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False
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True or false? Infection rates are a traditional outcome measure of care.
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True
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True or false? Donabedian’s criteria for assessing quality of care are no longer relevant.
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False
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True or false? Practice guidelines that can be repeated over and over again with the same result are always considered to be valid.
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False
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True or false? Report cards are used to assess patterns of an individual provider’s care.
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False
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Which of the following organizations have developed accreditation programs for managed care organizations?
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NCQA
URAC AAAHC All of the above |
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The Healthcare Effectiveness Data and Information Set (HEDIS) is a measurement tool used by approximately ___ of all health plans.
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90%
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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.
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Utilization management
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The first and most rigorous area of NCQA review is:
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A health plan's own internal quality control system
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___ is a set of standardized measures that look at plan performance across a variety of important dimensions, such as delivery of preventive health services, member satisfaction, and treatment efficacy for various illnesses.
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HEDIS
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The utilization management processes of plans seeking URAC accreditation must be:
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Based on up-to-date clinic principles
Performed by licensed clinical professionals Kept confidential All the above |
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The following entities must document quality improvement processes in order to gain URAC accreditation.
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Credentials verification organizations
Health plans Health websites All the above |
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Which of the following is NOT an organization typically accredited by the AAAHC?
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Hospital
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True or false? All managed care plans are required by the federal government to participate in accreditation and performance measurement programs.
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False
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True or false? All accredited health plans are required to report on their clinical performance though HEDIS.
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False
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True or false? Health plans growing via acquisition are expected to have a return that is typically higher than health plans achieving organic growth.
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False
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True or false? Health plans have typically invested heavily in sales and marketing, relative to other functional areas
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False
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True or false? The employee selection between carrier options chosen by the employer is called the second sale
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True
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True or false? A majority of U.S. employers’ health benefits plans are effective on January 1 of the subsequent year.
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True
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True or false? Health plans are increasingly looking at “retail” concepts of sales and marketing.
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True
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Traditional health plan customer segments include:
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Individual, small group, mid-market, large case
Medicare and Medicaid |
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In the employer-sponsored model, ___ is the process of qualifying a sales lead that typically gathers the information needed for rating and underwriting
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Prospecting
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What are intermediaries in the employer-sponsored business called?
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Brokers
Consultants |
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___ are the intermediary typically focused on smaller employers and are compensated based on commissions paid by the health plan.
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Brokers
Consultants |
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Health plan account managers are evaluated and compensated based on:
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Employer satisfaction
Employer retention Employee persistency |
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Beginning in 2014, what new distribution channel will become available?
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State health insurance exchanges
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Each of the following are characteristic of high performing direct markets sales, except:
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High touch, door-to-door selling
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___ is a key driver of the recent investment in improving health plan marketing.
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Emerging Medicare products
Growth of consumer-directed products |
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Typical health plan marketing functions include:
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Brand management
Market research |
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Each of the following is a traditional way to group a member, except:
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Claims experience
Lifestyle |
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Poor ___ is a key sales challenge for both the employer-sponsored and direct markets.
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Customer insight
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What are the four primary claims core competencies?
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Transactional processing, quality control, service delivery, and information management.
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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.
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True
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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.
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False. This is the definition of auto adjudication.
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True or false? Staffing ratios for the claims capability depend on the number needed to meet volume demands while maintaining quality standards and not relying on overtime hours as a permanent solution.
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True
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True or false? “Upstream” quality control refers to the processes and system files that govern and enable automatic and manual claims adjudication. “Downstream” quality control refers primarily to the claims capability itself.
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True
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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.
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True
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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.
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False
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Today’s transactional processing systems auto adjudicate on average what percentage of claims that are accepted into the processing system.
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75%
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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?
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Inventory receipts
Timely filing limits Turnaround time based on the date the MCO received the claim, Claims lag IBNR |
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Subrogation is defined as:
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The right to recover any damages the member may receive from a third party who assumes responsibility for an accidental injury
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Briefly explain the history of health care fraud in the United States.
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Health care fraud as a crime gained the attention of the government in the mid-1980s when the Federal False Claims Act was amended with the intent that it could be applied to false claims against Medicare and Medicaid. JFK Harvard Professor Malcolm Sparrow is a pivotal researcher and theorist in this area. Critical thinking around how to more effectively fight health care fraud has emerged as the government seeks more ways to fund legitimate health care needs.
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Describe the fraud triangle and what it represents.
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The fraud triangle represents common theories on rationale for fraud. The three elements include Opportunity, Pressure, and Rationalization. For fraud to occur, these three elements must typically be present.
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List the seven elements of compliance and describe why they are important to fraud control.
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1. Policies and Procedures
2. Compliance Officer and other appropriate oversight bodies 3. Effective training and education 4. Effective lines of communication 5. Enforcement of standards through well publicized disciplinary guidelines 6. Internal monitoring and auditing 7. Prompt responses to detected offenses and corrective action 8. The government believes that if these elements are effectively implemented that fraud in health care will be significantly prevented or mitigated. |
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List three effective forms of health care fraud control.
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Data analysis combined with human review
Carefully monitoring patient complaints for red flags Coordination with local or national prevention groups and task forces Prepayment claims review and analysis Establishing and monitoring ethics and compliance hotlines |
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True or false? Health Care Fraud is not an issue for managed care organizations.
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False. Managed Care Organizations are also at risk for health care fraud though their focus is beyond claims and CPT codes.
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True or false? Effective fraud control must include ongoing and agile enhancements to efforts of fraud detection and prevention.
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True
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True or false? Fraud control effectiveness is easy to measure and assess.
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False. Fraud control is very difficult to effectively measure and assess because of the many complex contributing factors and the failure of the industry to distinguish between payment accuracy and fraud control.
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True or false? Miami, Florida is known as the “ground zero” for health care fraud.
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True
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True or false? Durable Medical Equipment Suppliers are considered high risk operations for fraud control.
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True
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Common types of health care fraud include:
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Billing for services not performed
Billing for more drugs than dispensed Duplicate billing Identity theft to obtain care Forging prescriptions |
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True or false? Member services and membership services are synonymous terms.
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False
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True or false? Although important, the provision of general information to members should not be considered to be one of the key aspects of member services.
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False
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True or false? It is important for all CSRs to be able to address all aspects of plan operations.
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False
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True or false? There is no legal distinction between a member complaint and a grievance.
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False
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True or false? Appeal of coverage denial reviews are a distinctly formal process governed by both state and federal laws.
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True
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What services is Member services responsible for?
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Providing information to members
Helping members with any problems Handling member grievances and complaints Tracking and reporting patterns of problems encountered Enhancing the relationship between the members of the plan and the plan itself |
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Proactive approaches to member services typically include what type of services?
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Member education programs
Soliciting member suggestions and recommendations Developing special services, affiliations, and health promotion activities |
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Member services is responsible for all of the following activities, except:
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Adjudicating claims
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Which of the following is the leading reason for member complaints?
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Claims issues
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The greatest volume of interactions between an health plan and its members will occur by means of:
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Telephone
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Critical measures in the contact center include:
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Abandon rate
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Which is not a key supporting function of the member services center?
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Member enrollment
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___ involves gathering information about applicants or groups of applicants to determine an adequate, competitive, and equitable rate at which to insure them.
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Underwriting
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___ involves calculating the premium to be charged for a specific individual or group on the basis of information gathered during the ___ process.
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Rating, underwriting
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The best data source for any health plan is ___ because it implicitly recognizes all the plan-specific characteristics.
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Experience
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___ rates are high enough to generate sufficient revenue to cover all claims and other plan expenses and to yield an acceptable return on equity.
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Adequate
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___ rates will approximate any given group’s costs without an unreasonable amount of cross-subsidization across groups.
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Equitable
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Why is historical persistency an important factor to consider when underwriting?
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There are significant fixed costs to write a new group
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Applicants/groups with poor credit histories may be required to do which of the following?
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Produce some form of collateral
Produce a letter of credit Pay premiums in advance of the coverage period |
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The rate formula typically adjusts the base rate for all of the following factors except:
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Eating habits
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___ is the term for the rate at which medical services are used.
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Utilization
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The ACA introduced which type of program?
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Risk Adjustment
Risk Sharing State Exchanges |
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The minimum loss ratio is ___% for individuals and small groups and ___% for large groups under the ACA.
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80%, 85%
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Effective underwriting at issue focuses on what four areas?
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•Health status
•Ability to pay the premium •Other coverage •Historical persistency |
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Information gathered to determine an applicant’s ability to pay premiums might include:
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Income and credit history
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True or false? Coordination of benefits allows insurers to keep premiums lower.
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True
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True or false? Dependent Coverage is extended to age 29 under the Affordable Care Act (ACA).
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False
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A managed care information system should be relied on for what core operational competencies?
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Benefit configuration
Employer group and member enrollment Claims payment Premium management Provider enrollment, contracting and credentialing Customer services |
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List at least three EDI X12 transaction standards.
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834 for enrollment (which includes adds, updates, terminations)
837 for claims 270, 271, and 271R for eligibility inquiry request, eligibility reply and eligibility roster respectively 835 for remittance advice (or explanation of payment) 278 for referral and authorization 276 and 277 for claims inquiry request and claims status reply respectively 820 for premium payments. |
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List two key legislative mandates that have included information technology for MCO.
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• HIPAA
• PPACA • HITECH |
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Name three actions that a MCO can take to ensure the security and protection of electronic health information.
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• Prevention
• Audit • Monitor |
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Providers, employers, agents, and members expect many health plan services to be available on-line. The preferred approach to allow access is ___:
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Through web-portals and interactive voice response systems.
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List three examples of how MCO can further leverage technologies to improve service and the overall experience for the member by doing the unexpected.
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•By using informatics, proactively outreaching to educate members when a change in benefits has occurred in the new plan year. For example, calling the member when they convert to a high deductible product to remind them that the provider may want to collect for the entire visit so that the member is prepared to pay. Another example is outreaching to the member on his or her birthday to offer a greeting, but to also proactively ask if they have any questions about their benefit or have feedback on his or her experience with the MCO.
•Provide a seamless transition between the web, phone and in-person experiences. For example, while using online chat, a member can request that a customer service agent calls him or her. When the phone rings, it is the same individual that the member was chatting with online. The agent knows exactly what the member is inquiring about with no need to repeat anything. •Provide a “call back when convenient” feature by providing the date, time and phone num |
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True or false? MCO rely greatly on information systems to reduce costs and improve service.
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True
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True or false? Claims processing is the primary differentiator between health plans in the marketplace.
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False
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True or false? The most common form of claims submission is electronic.
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True
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True or false? The largest opportunity to improve healthcare utilization, quality, and cost is through proactive and intensive medical and case management leverage medical management software.
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True
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Which of the following represents the largest group of individuals in the Medicaid program?
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Persons who are low income with dependents
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Which statement is not true regarding why specialized plans are more successful in Medicaid managed care?
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Medicaid focused plans are only owned by health systems.
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Which of the following is NOT a reason for the growing interest in Medicaid programs developing plans to serve dually eligible beneficiaries who also have Medicare coverage?
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Dually eligible persons are eager to enroll in prepaid health plans
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Which of the following groups represent the largest expenditures for the Medicaid program?
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Persons receiving long term care in nursing homes
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What safety net providers were developed in the last 40 years to bridge and close the access gap for Medicaid beneficiaries?
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FQHCs
RHCs Community clinics, mental health clinics and outpatient clinics |
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What is the single most significant piece of social legislation since 1965?
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The Patient Protection & Affordable Care Act of 2010
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What is the single largest factor contributing to poor health outcomes?
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Poverty
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True or false? The most common reason cited by physicians for limiting their practice to Medicaid consumers was low reimbursement rates.
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True
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True or false? Given the low payment rates in Medicaid, there is no interest in developing incentives or pay-for-performance programs.
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False
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True or false? Consumers and small employers may shop for and purchase health insurance through the Exchange as a result of the Children’s Health Insurance Reauthorization Act of 2009.
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False
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What is the summary plan description under ERISA?
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The summary plan description is a booklet that describes the operative provisions of a plan in lay terms.
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What federal agency has promulgated regulations setting forth minimum requirements for employee benefit plan procedures pertaining to claims for benefits by plan participants and beneficiaries?
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The U.S. Department of Labor
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True or false? State mandated benefits laws apply to self-funded employee benefits plans.
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False
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True or false? State mandated benefits laws apply to insured employee benefits plans.
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True
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True or false? ERISA preempts all state laws.
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False
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True or false? ERISA applies only to self-funded health plans.
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False
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True or false? ERISA requires expedited review for claims involving urgent care.
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True
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True or false? HIPAA mandates that federal confidentiality regulations overrule state laws regardless of whether or not state laws impose more stringent requirements or standards.
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False
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Which of the following is FALSE regarding HIPAA regulation?
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State laws regulating health insurance must always be preempted by HIPAA.
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Which of the following does HIPAA regulate?
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Electronic communications between payers and providers
Portability and access standards Guaranteed renewability of group coverage |
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Which of the following electronic transactions does HIPAA NOT standardize?
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EMR
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