QM Ch. 10
Terms in this set (12)
Which of the following situations is an example of prospective utilization review?
a healthy plan evaluates the medical necessity of a member's upcoming surgery
Which of the following is an example of overuse of healthcare resources
Physician prescribes antibiotics for a patient with a viral cold
Which of the following sources is used to identify medically necessary services
clinical practice guidelines
Which of the following activities is a responsibility of the physician advisor for hospital utilization management functions
evaluate the medical necessity of patient care services
The primary purpose of utilization management is to
eliminate under and overuse of health services
Which of the following tasks is commonly done by hospital case managers
arrange for medical services that patients need after discharge
Which of the following is the health plan reimbursement system that rewards care providers for achieving cost performance expectations
pay for performance
Which of the following groups require managed care organizations to have a written utilization management plan
National committee for quality assurance
A hospital utilization committee wants to ensure that patients undergoing knee replacement surgery receive appropriate services. Which job aid could be created to remind care providers of the key interventions that should occur on each day of a knee surgery patient's hospitalization.
which of the following activities is not a component of utilization management
evaluate the competence of care providers
Which of the following factors is not considered when determining the medical necessity of a healthcare service?
Convenience of the patient or the provider
The requirement that hospitals have a utilization review committee is found in the
Medicare conditions of participation
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