Question

(Spts) 14) Al of the following activities are steps in medical necessity and utilization review EXCEPT: Initial clinical review Peer clinical review Appeal consideration Administrative review 15) All of the following activities are service management tools used in controlling costs EXCEPT: (Spts) Applying an episode-of-care payment system Determining medical necessity and utilization review Assigning the primary care provider as gatekeeper to specialized services through referrals and prior authorizations Case and prescription management 16) Which of the following is a disadvantage of carve outs in managed care plans? S ) Decrease the risk and cost to the MCO Reduce cherry picking Fragmentation of care and decreased access to care Better management of condition by specialist instead of by PCP MacBook Air

Answer 1

14. Administrative review

15. applying an episode of care payment system as it include capitated reimbursement and global payment

16. Fragmentation of care and decreased access to care