Health plans that offer healthcare programs for Medicare beneficiaries have a strong financial incentive for identifying high-risk seniors as early as possible. The identification of high-risk seniors is typically accomplished through the use of
The following statement(s) can correctly be made about the use of screening for secondary prevention:
Screening activities may involve specialty care providers as well as primary care providers (PCPs) and the health plan
Secondary prevention often results in more utilization of services immediately following screening
Screening focuses on members who have not experienced any symptoms of a particular illness
Drugs included in a health plan's formulary can be classified according to how freely they can be prescribed. By definition, a drug that requires some sort of review or approval by a plan physician or group of physicians before the prescription can be filled is
The Hall Health Plan gathered objective clinical information about the recommended uses and dosages of angiotensin-converting enzyme (ACE) inhibitors and presented the information to network providers to illustrate the appropriate use of these frequently prescribed and expensive drugs. This information indicates that Hall most likely educated its network providers through the use of
Readiness is an important consideration for the development of health promotion programs. Readiness refers to
The following statements are about chronic and disabling conditions among children eligible for Medicaid. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.
Comorbidity can have a significant impact on the effective implementation of disease management programs. Comorbidity can correctly be defined as the
Outcomes management is a tool that health plans use to maximize all the results associated with healthcare processes. The following statement(s) can correctly be made about outcomes management:
1. The goal of outcomes management is to identify and implement treatments that are costeffective and deliver the greatest value
2. Outcomes management introduces performance as a critical factor in the assessment and improvement of outcomes
Vision care is typically separated into two categories: routine eye care and clinical eye care. The standard benefit plans offered by most health plans include coverage for
Routine eye care
Clinical eye care
The following statement(s) can correctly be made about utilization guidelines:
When developing utilization guidelines, health plans balance evidence-based criteria with experience-based criteria
Utilization guidelines indicate when a UR nurse should refer a decision to a physician reviewer
Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide should Mr. Farrell become incapacitated.
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Decisions regarding Mr. Farrell's end-of-life care are legally the right and responsibility of
Health plans that choose to contract with external organizations for pharmacy services typically contract with pharmacy benefit managers (PBMs). Functions that a PBM typically performs for a health plan include
Managing the costs of prescription drugs
Promoting efficient and safe drug use
Determining the health plan's internal management responsibilities for pharmacy services
Health plans communicate proposed performance changes through action statements. Select the answer choice containing an action statement that includes all of the required elements.
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
Medical management programs often require the analysis of many types of data and information. __________________ is an automated process that analyzes variables to help detect patterns and relationships in the data.
By definition, the development and implementation of parameters for the delivery of healthcare services to a health plan's members is known as
