HOM 5307 #2 exam questions and
answers
Technique is used by many pharmaceutical companies with health plans and PBMs to
increase formulary access and utilization of specific products: - ANSWERS 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)
- ANSWERS False
The majority of prescriptions for behavioral health medications are written by non
psychiatrist. (T/F) - ANSWERS True
Physicians treating gynecological patients diagnose substance abuse approximately
30% of the time. (T/F) - ANSWERS False
Approximately 50% of behavioral care spending is associated with what percentage of
patients? - ANSWERS 5%
Which organization does not accredit managed behavioral health care companies? -
ANSWERS 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) - ANSWERS True
Pay for performance (P4P) cannot be applied to behavioral health care providers. (T/F)
- ANSWERS False
HEDIS is the most widely used set of measures for reporting on managed behavioral
health care. (T/F) - ANSWERS True
What entities must document quality improvement processes in order to gain URAC
accreditation - ANSWERS Credentials verification
Organizations
Health websites
Health plans
, What organization typically accredited by the (Accreditation Association of Ambulatory
Health Care) AAAHC? - ANSWERS Clinic
Dental Office
What organizations have developed accreditation programs for managed care
organizations - ANSWERS NCQA
URAC
AAAHC
The Healthcare Effectiveness Data and Information Set (HEDIS) is a measurement tool
used by about______ of all health plans - ANSWERS 90%
All managed care plans are required by the federal government to participate in
accreditation and performance measurement programs. (T/F) - ANSWERS False
All accredited health plans are required to report on their clinical performance though
HEDIS. (T/F) - ANSWERS 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 - ANSWERS HEDIS
The utilization management processes of plans seeking URAC accreditation must be: -
ANSWERS Performed by licensed clinical professionals
Based on up to date clinical principles
To earn NCQA accreditation, an organization must meet_______standards designed to
ensure that this key health plan function promotes good medicine rather than acting as
an arbitrary barrier to care. - ANSWERS Utilization Management
The first and most rigorous area of NCQA review is - ANSWERS a health plan's own
internal quality control system
What two significant developments that have direct impact on the claims capability: -
ANSWERS 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) - ANSWERS True
answers
Technique is used by many pharmaceutical companies with health plans and PBMs to
increase formulary access and utilization of specific products: - ANSWERS 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)
- ANSWERS False
The majority of prescriptions for behavioral health medications are written by non
psychiatrist. (T/F) - ANSWERS True
Physicians treating gynecological patients diagnose substance abuse approximately
30% of the time. (T/F) - ANSWERS False
Approximately 50% of behavioral care spending is associated with what percentage of
patients? - ANSWERS 5%
Which organization does not accredit managed behavioral health care companies? -
ANSWERS 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) - ANSWERS True
Pay for performance (P4P) cannot be applied to behavioral health care providers. (T/F)
- ANSWERS False
HEDIS is the most widely used set of measures for reporting on managed behavioral
health care. (T/F) - ANSWERS True
What entities must document quality improvement processes in order to gain URAC
accreditation - ANSWERS Credentials verification
Organizations
Health websites
Health plans
, What organization typically accredited by the (Accreditation Association of Ambulatory
Health Care) AAAHC? - ANSWERS Clinic
Dental Office
What organizations have developed accreditation programs for managed care
organizations - ANSWERS NCQA
URAC
AAAHC
The Healthcare Effectiveness Data and Information Set (HEDIS) is a measurement tool
used by about______ of all health plans - ANSWERS 90%
All managed care plans are required by the federal government to participate in
accreditation and performance measurement programs. (T/F) - ANSWERS False
All accredited health plans are required to report on their clinical performance though
HEDIS. (T/F) - ANSWERS 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 - ANSWERS HEDIS
The utilization management processes of plans seeking URAC accreditation must be: -
ANSWERS Performed by licensed clinical professionals
Based on up to date clinical principles
To earn NCQA accreditation, an organization must meet_______standards designed to
ensure that this key health plan function promotes good medicine rather than acting as
an arbitrary barrier to care. - ANSWERS Utilization Management
The first and most rigorous area of NCQA review is - ANSWERS a health plan's own
internal quality control system
What two significant developments that have direct impact on the claims capability: -
ANSWERS 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) - ANSWERS True
