HOM 5307 #2 EXAM QUESTIONS AND
ANSWERS 100% CORRECT.
Technique is used by many pharmaceutical companies with health plans and
PBMincrease formulary access and utilization of specific products: - ANSWER Rebates
for preferred formulary position
Health economic data, including a growing number of head-to-head clinical trials
Member copayment coupons to offset copayments
Recent legislation encourages separate lifetime limits for limits for behavioral care (T/F)
- ANSWER False
The majority of prescriptions for behavioral health medications are written by non
psychiatrist. (T/F) - ANSWER True
Physicians treating gynecological patients diagnose substance abuse approximately
30% of the time. (T/F) - ANSWER False
Approximately 50% of behavioral care spending is associated with what percentage of
patients? - ANSWER 5%
Which organization does not accredit managed behavioral health care companies? -
ANSWER American College of Mental Health Administration
Behavioral health care providers are paid under methodologies similar to those applied
to medical/surgical care providers. (T/F) - ANSWER True
Pay for performance (P4P) cannot be applied to behavioral health care providers. (T/F)
- ANSWER False
HEDIS is the most widely used set of measures for reporting on managed behavioral
health care. (T/F) - ANSWER True
What entities must document quality improvement processes in order to gain URAC
accreditation - ANSWER Credentials verification
Organizations
Health websites
Health plans
, What organization typically accredited by the (Accreditation Association of Ambulatory
Health Care) AAAHC? - ANSWER Clinic
Dental Office
What organizations have developed accreditation programs for managed care
organizations - ANSWER NCQA
URAC
AAAHC
The Healthcare Effectiveness Data and Information Set (HEDIS) is a measurement tool
used by about______ of all health plans - ANSWER 90%
What two significant developments that have direct impact on the claims capability: -
ANSWER Transition from ICD-9 to ICD-10 diagnosis and procedure codes
The Patient Protection and Affordable Care Act of 2010.
"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. (T/F) - ANSWER True
A participating provider is permitted to balance bill a member for any copayments,
coinsurance, or deductibles that are applicable to a claim payment. (T/F) - ANSWER
True
Why is data analysis an increasingly important health plan function? - ANSWER Cost
increases 2-3 times the consumer price index
Potential for improvements in medical management
Third-party consultants that specialize in data analysis and aggregate data across
health plans
All managed care plans are required by the federal government to participate in
accreditation and performance measurement programs. (T/F) - ANSWER False
All accredited health plans are required to report on their clinical performance though
HEDIS. (T/F) - ANSWER False
______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 - ANSWER HEDIS
ANSWERS 100% CORRECT.
Technique is used by many pharmaceutical companies with health plans and
PBMincrease formulary access and utilization of specific products: - ANSWER Rebates
for preferred formulary position
Health economic data, including a growing number of head-to-head clinical trials
Member copayment coupons to offset copayments
Recent legislation encourages separate lifetime limits for limits for behavioral care (T/F)
- ANSWER False
The majority of prescriptions for behavioral health medications are written by non
psychiatrist. (T/F) - ANSWER True
Physicians treating gynecological patients diagnose substance abuse approximately
30% of the time. (T/F) - ANSWER False
Approximately 50% of behavioral care spending is associated with what percentage of
patients? - ANSWER 5%
Which organization does not accredit managed behavioral health care companies? -
ANSWER American College of Mental Health Administration
Behavioral health care providers are paid under methodologies similar to those applied
to medical/surgical care providers. (T/F) - ANSWER True
Pay for performance (P4P) cannot be applied to behavioral health care providers. (T/F)
- ANSWER False
HEDIS is the most widely used set of measures for reporting on managed behavioral
health care. (T/F) - ANSWER True
What entities must document quality improvement processes in order to gain URAC
accreditation - ANSWER Credentials verification
Organizations
Health websites
Health plans
, What organization typically accredited by the (Accreditation Association of Ambulatory
Health Care) AAAHC? - ANSWER Clinic
Dental Office
What organizations have developed accreditation programs for managed care
organizations - ANSWER NCQA
URAC
AAAHC
The Healthcare Effectiveness Data and Information Set (HEDIS) is a measurement tool
used by about______ of all health plans - ANSWER 90%
What two significant developments that have direct impact on the claims capability: -
ANSWER Transition from ICD-9 to ICD-10 diagnosis and procedure codes
The Patient Protection and Affordable Care Act of 2010.
"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. (T/F) - ANSWER True
A participating provider is permitted to balance bill a member for any copayments,
coinsurance, or deductibles that are applicable to a claim payment. (T/F) - ANSWER
True
Why is data analysis an increasingly important health plan function? - ANSWER Cost
increases 2-3 times the consumer price index
Potential for improvements in medical management
Third-party consultants that specialize in data analysis and aggregate data across
health plans
All managed care plans are required by the federal government to participate in
accreditation and performance measurement programs. (T/F) - ANSWER False
All accredited health plans are required to report on their clinical performance though
HEDIS. (T/F) - ANSWER False
______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 - ANSWER HEDIS
