The following statements are about the characteristics of a utilization review (UR) program. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

1. A. A primary goal of UR is to address practice variations through the application of uniform standards and guidelines.
2. B. UR evaluates whether the services recommended by a member’s provider are covered under the benefit plan.
3. C. UR recommends the procedures that providers should perform for plan members.
4. D. A health plan’s UR program is usually subject to review and approval by the state insurance and/or health departments.

Correct Answer: C

The following statements are about the use of hospitalists to manage inpatient care. Select the answer choice containing the correct statement.

1. A. A patient who has been transferred to a hospitalist for management of inpatient care usually continues to receive care from the hospitalist after discharge.
2. B. Hospitalists are used primarily to manage care for obstetric, pediatric, and oncology patients.
3. C. In order to serve as a hospitalist, a physician must have a background in critical care medicine.
4. D. Hospitalists typically spend at least one-quarter of their time in a hospital setting.

Correct Answer: D

Outcomes management is a tool that health plans use to maximize all the results
associated with healthcare processes. The following statement(s) can correctly be made about outcomes management:
* 1. The goal of outcomes management is to identify and implement treatments that are cost- effective and deliver the greatest value
* 2. Outcomes management introduces performance as a critical factor in the assessment and improvement of outcomes

1. A. Both 1 and 2
2. B. 1 only
3. C. 2 only
4. D. Neither 1 nor 2

Correct Answer: A

The following statements are about disease management programs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

1. A. The focus of disease management is on responding to the needs of individual members for extensive, customized healthcare supervision.
2. B. Disease management programs serve to improve both clinical and financial outcomes for healthcare services related to chronic conditions.
3. C. Tools such as preventive care, self-care, and decision support programs are used to support both case management and disease management.
4. D. Disease management programs apply to both diseases and medical conditions that are not diseases, such as high-risk pregnancy, severe burns, and trauma.

Correct Answer: A

State governments serve as both regulators and purchasers of health plan services. The influence of state governments as purchasers is focused on

1. A. Medicare and TRICARE programs
2. B. Medicaid and workers’ compensation programs
3. C. Medicare and Medicaid programs
4. D. TRICARE and workers’ compensation programs

Correct Answer: B