Medical Management

Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the

Determine whether the following statement is true or false:

The key to successfully managing the quality and cost-effectiveness of healthcare services for Medicaid enrollees is to merge Medicaid recipients into existing plans.

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.

Comparing the quality of managed Medicare programs with the quality of FFS Medicare programs is often
difficult. Unlike FFS Medicare, managed Medicare programs

Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray's condition, her physician has prescribed Upzil, a medication that has Food and Drug Administration (FDA) approval only for the treatment of depression. Upzil has not been tested for safety or effectiveness in the treatment of migraine headache. Although Harbrace's medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray.

The following statement(s) can correctly be made about Harbrace's use of extra-contractual coverage:

1. Harbrace's medical policy most likely establishes the procedure that Harbrace used to evaluate the value of Upzil for treating Ms. Ray

2. One way for Harbrace to reduce the risk associated with extra-contractual coverage is by including an alternative care provision in its contracts with purchasers

The following statement(s) can correctly be made about the hospitalist approach to inpatient care management:

1. Management of inpatient care by hospitalists may significantly reduce the length of stay and the total costs of care for a hospital admission

2. Most health plans that use hospitalists do so through a voluntary hospitalist program

3. A hospitalist's familiarity with utilization management (UM) and quality management (QM) standards for inpatient care may reduce unnecessary variations in care and improve clinical outcomes

The following statement(s) can correctly be made about the characteristics of peer review:

1. Peer review is applicable to either single episodes of care or to entire programs of care

2. Most peer review is conducted concurrently

3. Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services furnished to Medicare and Medicaid recipients enrolled in health plans

Federal laws, such as the Employee Retirement Income Security Act (ERISA), the Balanced Budget Act (BBA) of 1997, and the Health Insurance Portability and Accountability Act (HIPAA), have affected medical management activities by health plans. Consider the following provisions of federal regulations:

Provision 1--Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered treatment and does not allow health plan members to obtain compensatory or punitive damages

Provision 2--Establishes electronic data security standards, which define the security measures that healthcare organizations must take to protect the confidentiality of electronically stored and transmitted patient information From the answer choices below, select the response that correctly identifies the federal laws that include Provision 1 and Provision 2, respectively.

Health plans arrange for the delivery of various levels of healthcare, including

1. Emergency care

2. Urgent care

3. Primary care delivered in a provider's office

In a ranking of these levels of care according to cost, beginning with the least expensive level of care and ending with the most expensive level of care, the correct order would be

Health plans conduct evaluations on the efficiency and effectiveness of their quality improvement activities.
With regard to the effectiveness of quality improvement plans, it is correct to say that