Question 1

Comorbidity can have a significant impact on the effective implementation of disease management programs. Comorbidity can correctly be defined as the

Options :

A : degree to which the progression of a disease or condition is understood

B : prevalence or rate of a sickness or injury within a given population

C : degree of severity of a particular disease or condition

D :

presence of a chronic condition or added complication other than the condition that requires medical treatment

Answer: D

Question 2

The following statement(s) can correctly be made about the scope of case management:

1. Case management incorporates activities that may fall outside a health plan’s typical

responsibilities, such as assessing a member’s financial situation

2. Case management generally requires a less comprehensive and complex approach to a course

of care than does utilization review

3. Case management is currently applicable only to medical conditions that require inpatient

hospital care and are categorized as catastrophic in terms of health and/or costs

Options :

A : All of the above

B : 1 and 2 only

C : 2 and 3 only

D : 1 only

Answer: D

Question 3

A health plan’s coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions: 1. In case of conflict between the purchaser contract and a health plan’s medical policy or benefits administration policy, the contract takes precedence 2. Purchaser contracts commonly exclude custodial care from their coverage of services and supplies 3. All of the criteria for coverage decisions must be included in the purchaser contract

Options :

A : All of the above

B : 1 and 2 only

C : 2 only

D : 3 only

Answer: B

Question 4

Benchmarking is a quality improvement strategy used by some health plans. With regard to benchmarking, it is correct to say that

Options :

A :

cost-based benchmarking reveals why some areas of a health plan perform better or worse than comparable areas of other organizations

B :

diagnosis-related groups (DRGs) are a source of benchmarking data that describe individual procedures and cover both inpatient and outpatient care

C :

patient billing records provide a much more accurate account of procedure costs for benchmarking than do current procedural terminology (CPT) codes

D : the focus of benchmarking for health plan has shifted from identifying the lowest cost practices to identifying best practices

Answer: D

Question 5

Michelle Durden, who is enrolled in a dental health maintenance organizations (DHMO) offered by her employer, is due for a routine dental examination. If the plan is typical of most DHMOs, then Ms. Durden

Options :

A : must pay the entire cost of the examination

B : must obtain a referral to a dentist from her primary care provider (PCP)

C : can schedule the examination without preauthorization of payment by the DHMO

D : can schedule an unlimited number of examinations and cleanings per year

Answer: C

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