HOM 5307 Questions Answered 100% Correct
The first step in developing a quality management program is to:
Understand consumer need
_____ involves calculating the premium to be charged for a specific individual or group on the
basis of information gathered during the _____ process.
Rating, underwriting
T or F: Health plans are increasingly looking at "retail" concepts of sales and marketing.
True
T or F: Infection rates are a traditional outcome measure of care.
True
The greatest volume of interactions between a health plan and its members will occur by
means of:
Telephone
Which are effective forms of health care fraud control?
-establishing and monitoring ethics and compliance hotlines
-prepayment claims review and analysis
-coordination with local or national prevention groups and task force
What safety net providers were developed in the last 40 years to bridge and close the access
gap for Medicaid beneficiaries?
-RHCs
-FQHCs
-Community clinics, mental health clinics, and outpatient clinics
T or F: HIPAA mandates that federal confidentiality regulations overrule state laws regardless
of whether or not state laws impose more stringent requirements or standards.
, False
Traditional health plan customer segments include:
-individual
-small group
-mid-market
-Medicare and Medicaid
The ACA introduced which type of program?
Risk adjustment
T or F: Health plans growing via acquisition are expected to have a return that is typically
higher than health plans achieving organic growth.
False
What are elements of compliance?
-prompt responses to detected offenses and corrective action
-policies and procedures & compliance officer and other appropriate oversight bodies
-effective training and education & effective lines of communication
-enforcement of standards through well publicized disciplinary guidelines & internal monitoring
and auditing
T or F: Process measures of health care performance focus on the context in which care and
services are not provided.
True
T or F: 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.
False
T or F: There is no legal distinction between a member complaint and a grievance.
The first step in developing a quality management program is to:
Understand consumer need
_____ involves calculating the premium to be charged for a specific individual or group on the
basis of information gathered during the _____ process.
Rating, underwriting
T or F: Health plans are increasingly looking at "retail" concepts of sales and marketing.
True
T or F: Infection rates are a traditional outcome measure of care.
True
The greatest volume of interactions between a health plan and its members will occur by
means of:
Telephone
Which are effective forms of health care fraud control?
-establishing and monitoring ethics and compliance hotlines
-prepayment claims review and analysis
-coordination with local or national prevention groups and task force
What safety net providers were developed in the last 40 years to bridge and close the access
gap for Medicaid beneficiaries?
-RHCs
-FQHCs
-Community clinics, mental health clinics, and outpatient clinics
T or F: HIPAA mandates that federal confidentiality regulations overrule state laws regardless
of whether or not state laws impose more stringent requirements or standards.
, False
Traditional health plan customer segments include:
-individual
-small group
-mid-market
-Medicare and Medicaid
The ACA introduced which type of program?
Risk adjustment
T or F: Health plans growing via acquisition are expected to have a return that is typically
higher than health plans achieving organic growth.
False
What are elements of compliance?
-prompt responses to detected offenses and corrective action
-policies and procedures & compliance officer and other appropriate oversight bodies
-effective training and education & effective lines of communication
-enforcement of standards through well publicized disciplinary guidelines & internal monitoring
and auditing
T or F: Process measures of health care performance focus on the context in which care and
services are not provided.
True
T or F: 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.
False
T or F: There is no legal distinction between a member complaint and a grievance.
