The following statements are about health plans’ use of electronic data interchange (EDI). Three of the statements are true and one is false. Select the answer choice containing the FALSE ALSE statement.
Correct Answer:C
The paragraph below contains two pairs of terms in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Health plans use both internal and external standards to assess the quality of the services that they provide. (Internal / External) standards are based on information such as published industry-wide averages or best practices of recognized industry leaders. Health plans primarily rely on (internal / external) standards to evaluate healthcare services.
Correct Answer:D
The case management program director at the Nova Health Plan calculated the program’s ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:
Administrative costs for case management ..........$40,000
Actual medical care expenses for patients under case management ..........$680,000
Projected medical care expenses for the same patients without case management
..........$900,000
This information indicates that, for the previous quarter, Nova’s ratio of medical expense savings to case management administrative costs was
Correct Answer:C
The Midwest Health Plan delegated utilization review (UR) activities to the Tri-City Utilization Review Organization. After Tri-City improperly recommended denial of payment for services to a Midwest plan member, the plan member filed suit. The court ruled that Midwest was responsible for Tri-City’s actions because of the relationship between Midwest and Tri-City. This situation is an illustration of a legal concept known as
Correct Answer:A
Step-therapy is a form of prior authorization that reserves the use of more expensive medications for cases in which the use of less expensive medications has been unsuccessful. Step-therapy is appropriate for situations in which
* 1.A significant percentage of those treated with the initial therapy will require the second therapy
* 2.The delay created when a patient moves from one therapy to the next therapy will not cause serious or permanent effects
Correct Answer:C
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say
Correct Answer:B