ABQAURP EVALUATION EXAM 2025/2026 QUESTIONS
AND SOLUTIONS GRADED A+
✔✔What are Clinical pathways? - ✔✔Structured multidisciplinary plans of care designed
to support the implementation of clinical guidelines and protocols. They can be viewed
as algorithms in as much as they offer a flowchart format of the decisions to be made
and the care to be provided for a given patient for a given condition in stepwise
sequence
✔✔Four main components of Clinical Pathways: - ✔✔-Timeline
-The categories of care or activities and their interventions
-Intermediate and long term outcome criteria
-The variance record (to allow deviations to be documented and analyzed)
✔✔Disease Management is defined as: - ✔✔A system of coordinated health care
interventions and communications for populations with conditions in which patient self-
care efforts are significant
✔✔What is Demand Management? - ✔✔Strategy for cost containment and patient care
with a focus on healthy consumerism and healthy lifestyles. Seeks patient
empowerment with health promotion information with professional support through 24
hour hotlines. Help avoid unnecessary utilization of emergency rooms and office visits
for things that can be done over the phone.
✔✔Limitations of using claims as a data set? - ✔✔Validity: claims data is used to
generate reimbursement payment and contain numerous duplications and omissions
Reliability: do persons of comparable skill and knowledge using similar methods
complete all claims?
Coding Errors: there is great variation in coding processes and skewing due to financial
incentives. 'When analyzing a claims data set, it is impossible to know which factors
have influenced it, thereby making it statistically incorrect.
✔✔Why should you choose goal before collecting data? - ✔✔There is no reason to
study an issue if no intervention can reasonably occur to impact the finding. The
profiling effort must produce benefits to substantiate the resources expended.
✔✔What two systems did CMS implement in 2006 to integrate claims information and
improve its ability to detect fraud, waste, and abuse? - ✔✔Integrated Data Repository
(IDR) and One Program Integrity (One PI)
✔✔What are the six areas of program integrity activity monitoring CMS contracts private
entities to monitor? - ✔✔-Provider Audits
-Reviewing claims for medical necessity
, -Identifying and investigating fraud
-Ensuring that Medicare pays only for services for which it has primary responsibility
-Educating providers on Medicare billing procedures
-Identifying improper billing practices that affect both Medicare and Medicaid
✔✔What entity did CMS create in 2010 to consolidate responsibility for administering
and monitoring program integrity activities? - ✔✔Center for Program Integrity (CPI)
✔✔What are CPI's 4 areas? - ✔✔-Prevention
-Detection
-Recovery
-Transparency
✔✔What is the CNC? - ✔✔Compromised Number Checklist: a database of Medicare
beneficiary HICNs (Healthcare Insurance Claim Number) and provider ID numbers felt
to be compromise
✔✔What is the CTI "Four Pillar" approach? - ✔✔1. Assistance with medication self-
management.
2. Keeping an updated patient-centered record to facilitate information transfer between
care
providers.Scheduling timely follow-up appointments with primary or specialty care.
3. Understanding "red flag" events and what to do in response should one occur
✔✔Medicare Part A? - ✔✔Pays for inpatient hospital, SNF, home health (related to a
hospital stay), and hospice care - Financed by a 2.9% payroll tax split between
employees and employers
✔✔Medicare Part B? - ✔✔Pays for physician, outpatient hospital, ESRD, laboratory,
DME, certain home health, and other medical services. Part B coverage is voluntary
and funded 25% by premiums and 75% by general government revenues
✔✔Medicare part C? - ✔✔Medicare advantage program. The MA plans are are
generally private managed care companies that are paid by the government a capitated,
monthly payment to provide all Part A and B services, and also Part D services if
offered by the plan
✔✔Medicare Part D? - ✔✔Standard prescription drug benefit. Optional, beneficiaries
who choose to participate are responsible for covering a portion of the cost of their
prescription drugs
✔✔Medicaid? - ✔✔Cooperative federal-state program that provides medical care to
needy individuals. To qualify for federal funds states must submit their Medicaid plan to
CMS. CMS reviews to determine if plan complied with federal regulation that "assure
AND SOLUTIONS GRADED A+
✔✔What are Clinical pathways? - ✔✔Structured multidisciplinary plans of care designed
to support the implementation of clinical guidelines and protocols. They can be viewed
as algorithms in as much as they offer a flowchart format of the decisions to be made
and the care to be provided for a given patient for a given condition in stepwise
sequence
✔✔Four main components of Clinical Pathways: - ✔✔-Timeline
-The categories of care or activities and their interventions
-Intermediate and long term outcome criteria
-The variance record (to allow deviations to be documented and analyzed)
✔✔Disease Management is defined as: - ✔✔A system of coordinated health care
interventions and communications for populations with conditions in which patient self-
care efforts are significant
✔✔What is Demand Management? - ✔✔Strategy for cost containment and patient care
with a focus on healthy consumerism and healthy lifestyles. Seeks patient
empowerment with health promotion information with professional support through 24
hour hotlines. Help avoid unnecessary utilization of emergency rooms and office visits
for things that can be done over the phone.
✔✔Limitations of using claims as a data set? - ✔✔Validity: claims data is used to
generate reimbursement payment and contain numerous duplications and omissions
Reliability: do persons of comparable skill and knowledge using similar methods
complete all claims?
Coding Errors: there is great variation in coding processes and skewing due to financial
incentives. 'When analyzing a claims data set, it is impossible to know which factors
have influenced it, thereby making it statistically incorrect.
✔✔Why should you choose goal before collecting data? - ✔✔There is no reason to
study an issue if no intervention can reasonably occur to impact the finding. The
profiling effort must produce benefits to substantiate the resources expended.
✔✔What two systems did CMS implement in 2006 to integrate claims information and
improve its ability to detect fraud, waste, and abuse? - ✔✔Integrated Data Repository
(IDR) and One Program Integrity (One PI)
✔✔What are the six areas of program integrity activity monitoring CMS contracts private
entities to monitor? - ✔✔-Provider Audits
-Reviewing claims for medical necessity
, -Identifying and investigating fraud
-Ensuring that Medicare pays only for services for which it has primary responsibility
-Educating providers on Medicare billing procedures
-Identifying improper billing practices that affect both Medicare and Medicaid
✔✔What entity did CMS create in 2010 to consolidate responsibility for administering
and monitoring program integrity activities? - ✔✔Center for Program Integrity (CPI)
✔✔What are CPI's 4 areas? - ✔✔-Prevention
-Detection
-Recovery
-Transparency
✔✔What is the CNC? - ✔✔Compromised Number Checklist: a database of Medicare
beneficiary HICNs (Healthcare Insurance Claim Number) and provider ID numbers felt
to be compromise
✔✔What is the CTI "Four Pillar" approach? - ✔✔1. Assistance with medication self-
management.
2. Keeping an updated patient-centered record to facilitate information transfer between
care
providers.Scheduling timely follow-up appointments with primary or specialty care.
3. Understanding "red flag" events and what to do in response should one occur
✔✔Medicare Part A? - ✔✔Pays for inpatient hospital, SNF, home health (related to a
hospital stay), and hospice care - Financed by a 2.9% payroll tax split between
employees and employers
✔✔Medicare Part B? - ✔✔Pays for physician, outpatient hospital, ESRD, laboratory,
DME, certain home health, and other medical services. Part B coverage is voluntary
and funded 25% by premiums and 75% by general government revenues
✔✔Medicare part C? - ✔✔Medicare advantage program. The MA plans are are
generally private managed care companies that are paid by the government a capitated,
monthly payment to provide all Part A and B services, and also Part D services if
offered by the plan
✔✔Medicare Part D? - ✔✔Standard prescription drug benefit. Optional, beneficiaries
who choose to participate are responsible for covering a portion of the cost of their
prescription drugs
✔✔Medicaid? - ✔✔Cooperative federal-state program that provides medical care to
needy individuals. To qualify for federal funds states must submit their Medicaid plan to
CMS. CMS reviews to determine if plan complied with federal regulation that "assure
