AHIP BUNDLED EXAMS FULL QUESTIONS AND
CORRECT ANSWERS COMPLETE SOLUTION
◉ annual increase in premiums.
Answer: - result from consumer/government limitations placed on
managed care
- other factors: higher provider fees, increased use of tech in delivery
of care, health care fraud and other admin costs
◉ Provider network.
Answer: * to assure quality/cost control and addressing population
health issues
1. closed network (specific providers)
2. open network (not set of providers)
3. defined network w/ out-of-network coverage
(specific providers but any out-of-network services = larger portion
of costs)
quality control - credentialing providers (Verify and review licenses
to avoid malpractices)
,cost control - negotiate fee payments w/ in-network providers =
high patient volume for lower per-unit costs
* makes costs of plans more predictable
addressing population health issues - focus network on certain
population issues such as obesity
- providers do this w/ communication or w/ action/outcome based
payment incentives
◉ 4 most common functions preformed by health plan medical
departments.
Answer: 1) clinical quality
2) utilization management
3) population health management
4) pharmacy benefit
◉ Clinical quality.
Answer: * determines health plans medical policies, determines
what the right care is, determines timing of right care
- turn data into quality medical care
* collect immediately and unlimited data
- review and use to identify best practices/trends
, - clinical quality teams turn data into valuable info that is used to
assess and track quality of care
◉ evidence-based medicine.
Answer: Healthcare services based on clinical methods that have
been thoroughly tested through controlled, peer-reviewed
biomedical studies --> apply it to clinical decision-making process
(EBM) or evidence based practice (EBP)
* clinical quality teams work with physicians from within org to
review, debate, revise, and ultimately approve the health plans
medical policies
◉ National Committee for Quality Assurance (NCQA).
Answer: non-profit organization in the United States that works to
improve health care quality through the administration of evidence-
based standards, measures, programs, and accreditation. The
private, nonprofit organization operates on a formula of measure,
analyze, and improve. And it aims to build consensus across the
industry by working with policymakers, employers, doctors, and
patients, as well as health plans.
* under utilization = problematic too
◉ Accreditation.
CORRECT ANSWERS COMPLETE SOLUTION
◉ annual increase in premiums.
Answer: - result from consumer/government limitations placed on
managed care
- other factors: higher provider fees, increased use of tech in delivery
of care, health care fraud and other admin costs
◉ Provider network.
Answer: * to assure quality/cost control and addressing population
health issues
1. closed network (specific providers)
2. open network (not set of providers)
3. defined network w/ out-of-network coverage
(specific providers but any out-of-network services = larger portion
of costs)
quality control - credentialing providers (Verify and review licenses
to avoid malpractices)
,cost control - negotiate fee payments w/ in-network providers =
high patient volume for lower per-unit costs
* makes costs of plans more predictable
addressing population health issues - focus network on certain
population issues such as obesity
- providers do this w/ communication or w/ action/outcome based
payment incentives
◉ 4 most common functions preformed by health plan medical
departments.
Answer: 1) clinical quality
2) utilization management
3) population health management
4) pharmacy benefit
◉ Clinical quality.
Answer: * determines health plans medical policies, determines
what the right care is, determines timing of right care
- turn data into quality medical care
* collect immediately and unlimited data
- review and use to identify best practices/trends
, - clinical quality teams turn data into valuable info that is used to
assess and track quality of care
◉ evidence-based medicine.
Answer: Healthcare services based on clinical methods that have
been thoroughly tested through controlled, peer-reviewed
biomedical studies --> apply it to clinical decision-making process
(EBM) or evidence based practice (EBP)
* clinical quality teams work with physicians from within org to
review, debate, revise, and ultimately approve the health plans
medical policies
◉ National Committee for Quality Assurance (NCQA).
Answer: non-profit organization in the United States that works to
improve health care quality through the administration of evidence-
based standards, measures, programs, and accreditation. The
private, nonprofit organization operates on a formula of measure,
analyze, and improve. And it aims to build consensus across the
industry by working with policymakers, employers, doctors, and
patients, as well as health plans.
* under utilization = problematic too
◉ Accreditation.
