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50 Cards in this Set
- Front
- Back
True or false? Process measures of health care performancefocus on the context in which care and services are provided. |
False |
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True or false? Practice guidelines that can be repeated over and over again with the same result are always considered to be valid. A. True |
False |
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True or false? Report cards are used to assess patterns of an individual provider's care. |
False |
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True or false? All managed care plans are required by the federal government to participate in accreditation and performance measurement programs. |
False |
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True or false? All accredited health plans are required to report on their clinical performance though HEDIS. |
False |
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True or false? A majority of U.S. employers' health benefits plans are effective on January 1 of the subsequent year. |
True |
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True or false? Payers directly bill the employees in a group medical plan. |
False |
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True or false? Employers can restrict enrollment in their group plan to full-time employees only. |
True |
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True or false? Medicare is provided without cost to the Medicare beneficiary. |
False |
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True or false? The various election periods for Medicare Advantage include: |
True |
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True or false? Two significant developments that have direct impact 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. |
True |
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True or false? 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. |
False |
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True or false? A participating provider is permitted to balance bill a member for any copayments, coinsurance, or deductibles that are applicable to a claim payment. |
True |
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True or false? 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. |
False |
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True or false? The use of utilization guidelines targets only managed care patients and does not have an impact on the care of non-managed care patients. |
False |
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True or false? Nurse-on-call or medical advice programs are considered demand management strategies. |
True |
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True or false? UM focuses on telling doctors and hospitals what to do. |
False |
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True or false? Hospital utilization varies by geographical area. |
True |
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True or false? The Affordable Care Act will reduce enrollee cost sharing during the drug coverage gap. |
True |
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True or false? The Affordable Care Act will phase in plan payment changes to bring payments closer to average FFS amounts. |
True |
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True or false? CMS requires MA plans to have a quality improvement program to measure program performance. |
True |
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True or false? The most common reason cited by physicians for limiting their practice to Medicaid consumers was low reimbursement rates. |
True |
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The first step in developing a quality management program is to: |
C. Understand consumer need. |
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A set of causes and conditions that come together in a series of steps to transfer inputs into outcomes is called: |
B. Structure. |
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Which of the following organizations have developed accreditation programs for managed care organizations? |
E. All of the above. (NCQA, URAC, AAAHC) |
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The Healthcare Effectiveness Data and Information Set (HEDIS) is a measurement tool used by approximately ___ of all health plans. |
A. 90%. |
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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. |
B. Utilization management. |
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The following entities must document quality improvement processes in order to gain URAC accreditation. |
E. All of the above.(A. Credentials verification organizations. B. Health plans. C. Health Web sites.) |
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___ are the intermediary typically focused on smaller employers and are compensated based on commissions paid by the health plan. |
A. Brokers. |
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Beginning in 2014, what new distribution channel will become available? |
B. State health insurance exchanges. |
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Traditional health plan customer segments include: |
C. Both A and B. (A. Individual, small group, mid-market, large case. B. Medicare and Medicaid.) |
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Which of the following is not considered a "life event"? |
D. Changing employment. |
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Beginning in 2014, which of the following organizations will be able to enroll individuals into a health plan? |
C. State health insurance exchanges. |
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Today's transactional processing systems auto adjudicate on average what percentage of claims that are accepted into the processing system. |
D. 75% |
|
Subrogation is defined as: |
B. The right to recover any damages the member may receive from a third party who assumes responsibility for an accidental injury. |
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Which of the following aspects of the claims capability must be "counted" or measured in order to allocate adequate resources and verify financial assumptions about an insured population? |
F. All of the above.(A. Inventory receipts. B. Timely filing limits. C. Turnaround time based on the date the MCO received the claim. D. Claims lag. E. IBNR.) |
|
___ involves gathering information about applicants or groups of applicants to determine an adequate, competitive, and equitable rate at which to insure them. |
B. Underwriting. |
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___ involves calculating the premium to be charged for a specific individual or group on the basis of information gathered during the ___ process. |
A. Rating, Underwriting. |
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The best data source for any health plan is ___ because it implicitly recognizes all the plan-specific characteristics. |
C. Experience. |
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___ rates are high enough to generate sufficient revenue to cover all claims and other plan expenses and to yield an acceptable return on equity. |
B. Adequate. |
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___ rates will approximate any given group's costs without an unreasonable amount of cross-subsidization across groups. |
A. Equitable. |
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The rate formula typically adjusts the base rate for all of the following factors except: |
C. Eating habits. |
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___ is the term for the rate at which medical services are used. |
B. Utilization. |
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Which type of MA plan is experiencing an increase in availability and enrollment due to broad waivers from CMS? |
D. Group retiree plan. |
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Dual Eligible Special Needs Plans enroll individuals who are "dual eligible." Who are the "dual eligible"? A. Individuals who are eligible for Medicare and have Long-Term care insurance. B. Individuals who are eligible for Medicare and Medicaid. |
B. Individuals who are eligible for Medicare and Medicaid. |
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Which of the following is most likely to cause the rise of Medicare enrollment in MA plans over the next few decades? |
B. Baby Boomer interest in staying in managed care when becoming eligible for Medicare. |
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Which of the following represents the largest group of individuals in the Medicaid program? |
A. Persons who are low income with dependents. |
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Which of the following groups represent the largest expenditures for the Medicaid program? |
D. Persons receiving long term care in nursing homes. |
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What safety net providers were developed in the last 40 years to bridge and close the access gap for Medicaid beneficiaries? |
D. All of the above.(A. FQHCs. B. RHCs. C. Community clinics, mental health clinics and outpatient clinics.) |
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Which of the following is not in effect for all health benefits plans before 2014? |
B. Immediate elimination of annual maximum benefits. |