The measures used to evaluate healthcare quality are generally divided into three categories: process, structure, and outcomes. An example of a process measure that can be used to evaluate a health plan's performance is the:
Which of the choices below contains the four tools used by marketers that make up the 'promotion mix'?
Utilization management techniques that most HMOs use for hospital providers include:
Common characteristics of POS products are
The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential
Prescription drug benefits in Medicare can be obtained through:
The Koster Company plans to purchase a health plan for its employees from Intuitive HMO. Intuitive will administer the plan and will bear the responsibility of guaranteeing claim payments by paying all incurred covered benefits. Koster will pay for the he
The Stateside Health Plan uses the following outcomes measures to evaluate the quality of its diabetes disease management program.
Measure A: Incidence of foot ulcers among long-term diabetes patients
Measure B: Ability of long-term diabetes patients to m
In the CPT system, each service or procedure is identified by
The following statements are about information management in health plans. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:
The Madison Health Plan, a national MCO, and a local hospital system that operates its own managed healthcare network recently created a new and separate managed healthcare organization, the Pineapple Health Plan. Madison and the hospital system share own
The Gable MCO sometimes experience-rates small groups by underwriting a number of small groups as if they constituted one large group and then evaluating the experience of the entire large group. This practice, which allows small groups to take advantage
Which of the following statements is true?
When the Knoll Company purchased group health coverage from the Castle Health Maintenance Organization (HMO), the agreement between the two parties specified that the plan would be a typical fully funded plan. Because Knoll had been covered under a previous
Which of the following is NOT a preventive care initiative often used by health plans?
Certificate of Authority (COA) is subject to:
The National Committee for Quality Assurance (NCQA) is a nonprofit organization that accredits health plans and other healthcare organizations. Under the current NCQA accreditation program, a health plan's accreditation score is determined, in part, by pe
Which of the following is WRONG?
The following statements pertain to the federal requirements for minimum deductible & maximum out of pocket expeses for a high deductible health plan in the year 2006. Select the correct answer from the options given below.
In the following sections, we will describe some of the measures health plans use to evaluate the quality of the services and healthcare they offer their members.
Which of the following is the best description of what a 'Process measure' evaluates?
______________ HMOs can't medically underwrite any group – incl small groups.
Federal Employee Health Benefits Program (FEHBP) requires health plans offering services to federal employees and their dependents to provide
Al Marak, a member of the Frazier Health Plan, has asked for a typical Level One appeal of a decision that Frazier made regarding Mr. Marak's coverage. One true statement about this Level One appeal is that
Before the Leo Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the
As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members:
From the following choices, choose the definition that best matches the term health risk assessment (HRA)
Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called:
Immediate evaluation and treatment of illness or injury can be provided in any of the following care settings:
Because many patients with behavioral health disorders do not require round-the-clock nursing care and supervision, behavioral healthcare services can be delivered effectively in a variety of settings. For example, post-acute care for behavioral health di
In most cases, medical errors are caused by breakdowns in the healthcare system rather than by provider mistakes.
Greentree Medical, a health plan, is currently recruiting PCPs in preparation for its expansion into a new service area. Abigail Davis, a recruiter for Greentree, has been meeting with Melissa Cortelyou, M.D., in an effort to recruit her as a PCP in Green
During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, fo
A medical foundation is a not-for-profit entity that purchases and manages physician practices. In order to retain its not-for-profit status, a medical foundation must
General HMO is building a provider network and is considering Universal Hospital as an addition to its network. Minimum requirements that General should consider in determining whether Universal is qualified to participate in General's network include A.
In order to help review its institutional utilization rates, the Sahalee Medical Group, a health plan, uses the standard formula to calculate hospital bed days per 1,000 plan members for the month to date (MTD). On April 20, Sahalee used the following inf
Health savings accounts were created by which of the following laws:
Health plans use the following to determine the number of providers to add to a network:
Ed O'Brien has both Medicare Part A and Part B coverage. He also has coverage under a PBM plan that uses a closed formulary to manage the cost and use of pharmaceuticals. Recently, Mr. O'Brien was hospitalized for an aneurysm. Later, he was transferred by
One way in which health plans differ from traditional indemnity plans is that health plans typically
The Acme HMO recruits and contracts directly with a wide range of physicians—both PCPs and specialists—in its geographic area on a non-exclusive basis. There is no separate legal entity that represents and negotiates the contracts for the physicians. The
Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involves
One of the distinguishing characteristics of healthcare marketing is that many of the markets for health plans are national, not local markets.
One characteristic of disease management programs is that they typically
Provider integration has two components: operational integration and structural integration. An example of operational integration in health plans is the:
Merle Spencer has coverage under both Medicare Part A and Medicare Part B. Ms. Spencer recently was hospitalized for chest pains, and she incurred charges for:
One way in which a health plan can support an ethical environment is by
Phoebe Urich is covered by a traditional indemnity health insurance plan that specifies a $500 calendar-year deductible and includes a 20% coinsurance provision. When Ms. Urich was hospitalized, she incurred $3,000 in medical expenses that were covered by
Member satisfaction is a critical element of a health plan's quality management program. A health plan can obtain information about member satisfaction with various aspects of the health plan from
The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.
The following programs are part of the Alcove MCO's utilization management (UM) program:
With regard to the UM programs, it is most likely cor
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. In early efforts to manage healthcare costs, traditional indemnity health insurers included in their health pla
Primary care case managers (PCCMs) provide case management services to eligible Medicaid recipients. With regard to PCCMs it is correct to say that:
The following programs are part of the Alcove Health Plan's utilization management (UM) program:
With regard to the UM programs, it is most
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. Advances in computer technology have revolutionized the processing of medical and drug claims. Claims processing i
One true statement about community rating, a rating method commonly used by health plans, is that: