Exam 2 With 100% Correct Answers 2023, Exams of Advanced Education

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HOM 5307 Exam 2 With 100% Correct

Answers 2023

What technique is used by many pharmaceutical companies with health plans and PBMs to increase formulary access and utilization of specific products? A- Rebates for preferred formulary position B- Health economic data, including a growing number of head-to-head clinical trials C- Member copayment coupons to offset copayment D- All the above - Correct Answer-D- all of the above T/F Recent legislation encourages separate lifetime limits for behavioral care. - Correct Answer-false T/F The majority of prescriptions for behavioral health medications are written by non- psychiatrists. - Correct Answer-true T/F Physicians treating gynecological patients diagnose substance abuse approximately 30% of the time. - Correct Answer-false Approximately 50% of behavioral care spending is associated with what percentage of patients? A- 5% B- 10% C- 15% D- 20% - Correct Answer-A- 5% Which organization does NOT accredit managed behavioral health care companies? - Correct Answer-American College of Mental Health Administration Which organization(s) accredit managed behavioral health care companies? A- National Committee for Quality Assurance B- The Joint Commission C- Utilization Review Accreditation Commission D- Councile of Accreditation E- All the above - Correct Answer-E- all of the above

T/F

Behavioral health care providers are paid under methodologies similar to those applied to medical/surgical care providers. - Correct Answer-true T/F Pay for performance (P4P) cannot be applied to behavioral health care providers. - Correct Answer-false T/F HEDIS is the most widely used set of measures for reporting on managed behavioral health care. - Correct Answer-true (HEDIS = Healthcare Effectiveness Data and Information Set) which of the following entities must document quality improvement processes in order to gain URAC accreditation? A. Credentials verification organizations B. Health plans C. Health websites D. All the above - Correct Answer-D- all of the above What organization is typically NOT accredited by the AAAHC? A- hospital B- clinic C- dental office D- all of the above (**his question asked which organization is accredited by the AAAHC? but I couldn't find that answer on quizlet anywhere.) - Correct Answer-A- hospital What organizations have developed accreditation programs for managed care organizations? A- NCQA B- URAC C- AAAHC D- A and B only E- All of the above - Correct Answer-E- all of the above The Healthcare Effectiveness Data and Information Set (HEDIS) is a measurement tool used by approximately ___ of all health plans. A- 80%

B- 85%

C- 90%

D- 95% - Correct Answer-C- 90% T/F All managed care plans are required by the federal government to participate in accreditation and performance management programs. - Correct Answer-false T/F All accredited health plans are required to report on their clinical performance through HEDIS. - Correct Answer-false (HEDIS = The Healthcare Effectiveness Data and Information Set) _______ 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. A- CAHPS B- UM C- HEDIS D- CVO - Correct Answer-C- HEDIS (HEDIS = The Healthcare Effectiveness Data and Information Set) The utilization management processes of plans seeking URAC accreditation must be: A- Kept confidential B- Performed by licensed clinical professionals C- Based on up-to-date clinical principles D- B and C - Correct Answer-D- B and C (performed by licensed clinical professionals and based on up-to-date clinical principles) To earn NCQA accreditation, an organization must meet rigorous ______ standards designed to ensure that this key health plan function promotes good medicine rather than acting as an arbitrary barrier to care. A- Utilization management B- Preventive health services C- Credentialing D- B & C - Correct Answer-A- utilization management (NCQA = national committee for quality assurance) The first and most rigorous area of NCQA review is:

A- Credentialing B- Cost control processes C- A health plan's own internal quality control system D- Utilization management - Correct Answer-C- a health plan's own internal quality control system T/F Two significant developments that have direct impacts on the claims capability include the transition from ICD-9 to ICD-10 diagnosis and procedure codes and the Patient Protection and Affordable Care Act of 2010. - Correct Answer-true T/F "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. - Correct Answer-true T/F Benefit determination is the process of automatically determining eligibility and correctly applying benefits and payment terms for each claim using pre-determined rules without any human intervention. - Correct Answer-false T/F Staffing ratios for the claims capability depend on the number needed to meet volume demands while maintaining quality standards and not relying on overtime hours as a permanent solution. - Correct Answer-true Subrogation is defined as: A- The right to recover any damages the member may receive from a third party who assumes responsibility for an accidental injury B- The practice of coordinating with other group health insurance benefits C- Reducing payment liability due to a motor cycle accident D- Reducing payment liability due to a job-related injury or illness - Correct Answer-A- the right to recover any damages the member may receive from a third party who assumes responsibility for an accidental injury T/F A participating provider is permitted to balance bill a member for any amount not paid due to the application of a fee schedule or other provider payment mechanism - Correct Answer-false Today's transactional processing systems auto adjudicate on average what percentage of claims that are accepted into the processing system.

A- 70%

B- 75%

C- 80%

D- 85% - Correct Answer-B- 75% Which of the following is a method for providing a complete picture of care delivered in all health care settings? A- Inpatient DRGs B- ICD-9 / ICD-10 codes C- Health Maintenance Organizations D- Episodes of care - Correct Answer-D- episodes of care What specific factors other than diseases commonly affect severity of illness? A- Culture B- Geographic location C- Sex D- Age E- All the above - Correct Answer-E- all of the above (culture, geographic location, sex, and age) T/F Health care claims costs are typically distributed evenly across all members - Correct Answer-false Why is data analysis an increasingly important health plan function? A- Cost increases 2-3 times the consumer price index B- Potential for improvements in medical management C- Third-party consultants that specialize in data analysis and aggregate data across health plans D- All of the above - Correct Answer-D- all of the above More than _____ of members of employer-sponsored health plans have access to prescription. A- 70% B- 80% C- 90% D- 100% - Correct Answer-C- 90%

Which of the following is a typical complaint providers have about health plan provider profiling? A- I get different results using my own data B- My patients are sicker than other providers' patients C- The quality and cost measures used are not accurate enough D- All the above - Correct Answer-D- all of the above Electronic prescribing offers which of the following potential outcomes? A- Improvement in physician drug formulary prescribing conformance B- Reduction in drug interactions and resulting serious adverse effects C- Reduction in prescribing and dispensing errors D- All the above - Correct Answer-D- all of the above In January 2006, what large federal prescription drug program was implemented that offered pharmacy benefits to more than 40 million people at that time and is expected to increase by 30% throughout the next decade? A- The Department of Defense TRICOR program B- Public Health Service and Indian Health Service C- State Medicaid programs D- Medicare Part D - Correct Answer-D- Medicare Part D What statement is true regarding the trends of traditional, non-specialty drugs (mostly oral and topical drugs dispensed in community pharmacy) and specialty drugs (biotech, injectables, high-cost orals)? A- Most plans do not cover specialty drugs, except under the medical benefit, and specialty products, therefore, are of no serious cost consequence to pharmacy benefits. The number of generic drugs is declining due to lower manufacture costs and, as a result, traditional (non-specialty) drug products remain the focus of most of the pharmacy budget increases. B- Traditional drug costs are rising rapidly due to continued launch of new, expensive brand drugs, with only a few approved generics. The specialty market cost trend is declining as a result of biosimilar "generic" injectable products imported from Europe. C- Many expensive and popular traditional drugs are losing patent protection, and generics are driving a declining cost trend. A growing number of the drugs in the

pipeline for FDA approval are injectable products and the specialty drug trend, already at 20%, is expected to increase. D- The cost trends and utilization rates of both types of drugs are increasing by 20% per year or more, although specialty drugs are plateauing. - Correct Answer-C- Many expensive and popular traditional drugs are losing patent protection, and generics are driving a declining cost trend. A growing number of the drugs in the pipeline for FDA approval are injectable products and the specialty drug trend, already at 20%, is expected to increase. What is the common benefit design trend in commercial (employer group sponsored) prescription drug benefits? A- Increasing copayment amounts, especially for Tier 2 preferred brand drugs and Tier 3 non-preferred brand drugs. B- Increasing use of percent coinsurance, especially for Tier 3 and Tier 4 specialty tiers when available. C- Increasing number of consumer-directed health plan designs with higher front-end deductibles. D- All the above - Correct Answer-D- all of the above Select the technique for controlling drug benefits costs that MOST health plans and PBMs DO NOT routinely use. A- Tiered copayments B- Contracting with pharmacies for discounts C- Drug formularies D- Value-based insurance designs that assign "high-value" drugs to Tier 1 for ALL therapeutic categories. - Correct Answer-D- Value-based insurance designs that assign "high-value" drugs to Tier 1 for ALL therapeutic categories Desirable outcomes of tiered prescription member copayments are: A- Pharmacy gross profits rise and physicians are paid a formulary incentive B- Member costs increase and brand name drug use will double C- Brand drug use increases and generic drug use declines

D- The use of less expensive generic drugs increases and members save money by paying lower Tier 1 generic copayments - Correct Answer-D- The use of less expensive generic drugs increases and members save money by paying lower Tier 1 generic copayments One potential negative consequence of drug formularies with high copayments is: A- high copayments may be a barrier to adherence B- Decreased use of the most cost-effective medications C- Low copayments may be a barrier to adherence D- Increased use of brand drugs - Correct Answer-A- high copayments may be a barrier to adherence T/F Data used by health plans to pay claims can be used for analytic purposes. - Correct Answer-true T/F The goal of risk adjustment is to separate the effect of treatment from characteristics inherent to members. - Correct Answer-true T/F Employers are not interested in how their claims trend compared with other employers. - Correct Answer-false T/F Confidentiality is addressed in the Health Insurance Portability and Accountability Act. - Correct Answer-true T/F Administrative claims data cannot be used to calculate quality measures. - Correct Answer-false