AHM 540 QUESTIONS AND ANSWERS GRADE A+ SOLUTIONS

1. A medical service that a physician is proposing for a patient is reviewed to determine if it is necessary and appropriate. This describes a. Case management b. Clinical practice management c. Utilization management d. Disease management c. Utilization management 2. Darin has a spinal cord injury. The many healthcare services he receives from multiple providers are monitored and coordinated. What medical management program does this describe? a. Quality management b. Case management c. Disease management d. Clinical practice management b. Case management 3. Jeffrey has diabetes. He is trained to monitor and manage his condition, and his care is coordinated. What medical management program does this describe? a. Quality management b. Utilization management c. Clinical management d. Disease management d. Disease management 4. A health plan offers members immunizations, disease screenings, and assessments of their health risks. What medical management program does this describe? a. Preventative care b. Utilization management c. Case management d. Disease management a. Preventative care 5. Which statement comparing medical management are PPOs and HMOs is correct? a. PPOs tend to have less control over the care received by their members, so they have more and tighter medical management programs b. PPOs tend to have less control over the care received by their members, so they have fewer and looser medical management programs c. PPOs have traditionally focused on quality management, while HMOs have focused on utilization management d. PPOs are more likely to contract with large provider organizations and leave medical management to them b. PPOs tend to have less control over the care received by their members, so they have fewer and looser medical management programs 6. Which statement is correct about medical management in health plans? a. Lower-income people tend to have a greater need for disease management b. Younger people tend to have a greater need for case management and disease management c. Medical management is affected by the age and gender balance of a health plan's member population, but not by race or ethnicity d. Medical management is required for accreditation, but not affected by laws and regulations a. Lower-income people tend to have a greater need for disease management 7. Which health plan committee reviews cases in which the quality of care or provider performance is questionable or problematic? a. Quality management committee b. Pharmacy and therapeutics committee c. Peer review committee d. Medical advisory committee c. Peer review committee 8. Which statement about provider compensation and medical management is correct? a. If a health plan compensates providers by capitation, quality management is usually less necessary b. If a health plan compensates providers by capitation, utilization management may be less necessary c. If a health plan compensates providers by bundled payments, quality management is usually less necessary d. If a health plan offers providers targeted incentives (such as bonuses), these can be linked to utilization but not quality b. If a health plan compensates providers by capitation, utilization management may be less necessary 9. Which statement is correct about medical management in health plans? a. A health plan's physicians cannot be legally required to participate in and cooperate with medical management programs b. Information flows from the claims administration department to medical management programs, but rarely in the other direction c. Utilization review can reduce a health plan's legal and financial risk by ensuring that members receive appropriate services d. The member services department can educate members about medical management, but it provides little useful information to medical management programs c. Utilization review can reduce a health plan's legal and financial risk by ensuring that members receive appropriate services 10. If a health plan delegates a medical management function to another entity a. That entity, and not the plan, is responsible and accountable for the function b. Members served by that entity may be treated differently in terms of access, services, and coverage c. The plan will still have to devote considerable time and resources to oversight d. The plan may reduce its costs but rarely will improve quality c. The plan will still have to devote considerable time and resources to oversight 11. Which medical management function is least likely to be delegated to another entity? a. Quality management b. Utilization review c. Case management d. Disease management a. Quality management 12. If a health plan delegates a medical management function to another entity, can that entity sub delegate some activities to a third entity? a. No, this is forbidden by law b. Yes, but the plan will not be able to obtain accreditation c. Yes, but the plan is no longer accountable for the sub-delegated activates d. The plan may or may not allow this , or may place restrictions on it d. The plan may or may not allow this , or may place restrictions on it 1. Quality management... a. Must focus on quality, not costs b. Tends to increase costs c. Has no effect on costs d. Can also reduce costs through early detection and elimination of unnecessary services d. Can also reduce costs through early detection and elimination of unnecessary services 1. Quality management began... a. In the universities and was adopted by various industries, including healthcare b. In the federal government and spread to the private sector c. In manufacturing and was adopted by healthcare organizations d. In Europe and spread to the United States c. In manufacturing and was adopted by healthcare organizations 1. What are Donabedian's three dimensions of quality? a. Process, personnel, and product b. Structure, process, and outcomes c. Input, process, and outcomes d. Planning, performance, and measurement b. Structure, process, and outcomes 1. "Does the organization have an appropriate mix of healthcare professionals?" Which dimension of quality does this question relate to? a. Structure b. Technical process c. Interpersonal process d. Outcomes a. Structure 1. "Is treatment appropriate for the diagnosis? Which dimension of quality does this question relate to? a. Structure b. Technical process c. Interpersonal process d. Outcomes b. Technical process 1. What dimension(s) of quality is cultural competence part of? a. Structure b. Process c. Structure and Process d. Process and Outcomes c. Structure and Process 1. "Have the patient's symptoms diminished?" Which dimension of quality does this question relate to? a. Structure b. Technical process c. Interpersonal process d. Outcomes d. Outcomes 1. "Care should be respectful of and responsive to individual preferences, needs, and values." Which of the Institute of Medicine's six factors in healthcare quality does this express? CONTINUED......