Kogut's Managed Care Practice Test

These questions are part of the practice quiz. Start practicing

• Which feature most clearly characterizes a contract with significant outcome-based bonuses for performance?
• How does quality measurement reporting affect regulatory compliance and market competitiveness?
• Which formulary tier corresponds to preferred brand drugs (moderate cost)?
• In utilization management, what does step-down refer to?
• During the Act phase, what actions are typical?
• In a managed care context, what best explains episodic (bundled) payments?
• Which term corresponds to activities ensuring appropriate use of healthcare services?
• What is a formulary and how do formulary management strategies affect total cost of care?
• What best describes prior authorization in utilization management?
• Under capitation, which statement is true?
• What is the primary goal of network adequacy metrics?
• Which policy requires starting with a lower-cost drug and escalating only if treatment fails?
• Which is a commonly cited drawback of managed care in terms of access?
• How does Medicare Part C (Medicare Advantage) differ from Original Medicare in plan design?
• Which statement best describes network adequacy standards in a managed care contract?
• Which statement describes a managed care pro?
• Which statement best describes dual eligibility in managed care?
• What is a primary objective of a pharmacy benefit manager?
• What is step therapy in drug coverage decisions?
• In population health financing, risk pools primarily function to:
• Which of the following best captures the core outcomes used to evaluate the US healthcare system?
• Which formulary tier is typically designated for non-preferred brands with higher cost?
• Which service is not typically offered by pharmacy benefit managers?
• Which settings describe where healthcare is delivered?
• Which of the following groups represents the Big 3 PBMs?
• Why is credentialing important for providers in a managed care network?
• Which rebate is a fixed or percentage discount for formulary placement or tier status?
• What are risk pools and how do they function in risk-based contracts?
• Utilization management and differentiate prospective, concurrent, and retrospective reviews with examples.
• How do CAHPS and HEDIS differ, and what roles do they play in plan evaluation?
• In the Plan-Do-Check-Act cycle, what is the primary purpose of the 'Plan' phase?
• Which HIPAA privacy and security controls are essential for managed care operations?
• NCQA accreditation evaluation focuses on which areas?
• PBM Core Activities include which elements?
• Which statement best describes how the False Claims Act and Stark Law influence managed care operations?
• Which statement best describes how data analytics support managed care operations?
• What is care gap closure and how do plans identify and address gaps in preventive services?
• Which policy requires patients to use in-network providers for lower costs?
• What are the primary types of Drug Utilization Review (DUR)?
• Which statement about PCMH best describes its key attribute?
• What is the deductible?
• What term describes the drug price after rebates are applied?
• What is the primary goal of managed care?
• Which statement best defines network adequacy in managed care?
• Which process uses clinical and economic evidence to decide formulary inclusion?
• Describe CMS-HCC risk adjustment and its importance in capitation-based payments.
• What is HEDIS and how is it used in managed care?
• In medical necessity denials and appeals, which statement is correct?
• Which sectors commonly employ managed care professionals?
• How can managed care organizations address social determinants of health (SDoH) within care management?
• Which scenario illustrates a prospective prior authorization?
• What is the state government role?
• Why is NCQA accreditation significant for health plans?
• Which statement correctly describes the relationship between PMPM and episode-based payments?
• In CMS-HCC risk adjustment, which is true about how risk scores are determined?
• What is the primary purpose of a Quality Improvement plan in a managed care organization?
• What is therapeutic interchange and how is it used in formulary management?
• Explain the role of Pharmacy Benefit Management (PBM) in managed care.
• Which four dimensions are used to describe outcomes in the US healthcare system?
• Which term best describes a coordinated effort to improve health outcomes while controlling costs across a population?
• Which is a primary use of the Clinical-Minimum Index (CMI)?
• In value-based purchasing, which statement describes how payments are linked?
• Which formulary feature is associated with the lowest-cost options?
• What is pharmacoeconomic analysis used for in formulary decisions?
• Which agency is listed as part of the federal government's health oversight roles?
• Define post-acute care management and its importance for cost containment.
• What is a key characteristic of a narrow network in managed care?
• What is the cascade of care in managed care primarily focused on?
• Which entities are overseen by the federal government role in health care?
• Outline a case management approach for a patient with chronic heart failure in a managed care setting.
• What is the effect of a formulary on drug utilization?
• Which phase of the Plan-Do-Check-Act cycle involves implementing the planned changes?
• Which term describes a plan that blends PPO flexibility with HMO gatekeeper?
• Which statement best describes the role of managed care in care delivery?
• Which measure is primarily used to evaluate patient experience in plan evaluations?
• Which activity is most directly supported by clinical pathways in managed care?
• What role does NCQA accreditation play in managed care organizations?
• Which data source in population health management captures non-clinical factors?
• In a pay-for-performance arrangement, what is typically targeted to improve value?
• Why is care coordination essential in integrated delivery systems?
• What attribution approach is used by Accountable Care Organizations to assign accountability for cost and quality before the performance period begins?
• What characterizes a narrow network compared with a broad network?
• Which statement identifies essential components of a managed care contract?
• Which level of government licenses providers and facilities?
• Which statement best defines capitation with quality metrics?
• What is the impact of prior authorization on access, utilization, and patient satisfaction?
• Which term is defined as a fixed payment per patient per month regardless of services used?
• Which best describes the concept of inter-provider collaboration in managed care?
• How does patient engagement affect outcomes in managed care?
• What is the influence of STAR ratings on Medicare Advantage plans' operations?
• Which statement describes a managed care con?
• How do risk-based contracts differ from ACO attribution practices?
• How do clinical data registries support quality improvement?
• Which activity is essential to effective care coordination in managed care?
• Which utilization review occurs during care and includes discharge planning?
• Which best describes an essential contract term for managed care contracts?
• Which statement best describes the role of data governance in regulatory compliance and analytics?
• Who typically receives post-purchase manufacturer discounts?
• What is a Health Information Exchange (HIE) and why is it significant for care coordination?
• What does HEDIS stand for and what is its purpose?
• Which statement best defines medical necessity in managed care?
• What are risk corridors in capitated contracts?
• Which of the following is NOT a capitation-based payment model?
• What is the purpose of stop-loss in risk-sharing arrangements?
• Which item is not typically used as a quality measure in managed care?
• Describe utilization management and common tools used to control care.
• What are clinical pathways and what is their relationship to quality and cost?
• PBMs are organizations managing drug benefits for whom?
• Define a patient-centered medical home (PCMH) and its relevance to managed care.
• Post-acute care management coordinates transitions to which settings?
• How do privacy and data security considerations impact managed care operations?
• Which formulary tier corresponds to non-preferred brands (higher cost)?
• Which of the following is NOT typically considered a core managed care pharmacy competency?
• Which formulary tier corresponds to specialty drugs (high cost, coinsurance)?
• Which of the following is a common career path in managed care?
• What is the Managed Care Continuum?
• Who typically performs peer reviews to overturn a denial during the appeals process?
• Which statement best describes how patient-centered medical homes relate to managed care goals?
• Which statement differentiates case management from disease management?
• Pay-for-performance incentives reward providers based on which factor?
• What is the purpose of a grievance and appeals process in managed care?
• Which statement is true about the deductible?
• What defines an Accountable Care Organization (ACO) and its shared-savings mechanism?
• Which statement about interoperability is most accurate?
• Which plan is the least restrictive with minimal utilization management?
• What defines anomalous utilization in utilization management, and how is it addressed?
• Which of the following accurately describes a typical set included in Managed Care Organizations (MCOs)?
• Which statement defines capitation and describes its impact on incentives for utilization management?
• What is the primary purpose of a Formulary in a managed care setting?
• Which elements does managed care aim to balance?
• How do disease management and case management differ in terms of scope and approach?
• Which is a key antitrust consideration when forming provider networks in managed care?
• What is the term for pre-approval required before a drug is covered or dispensed?
• What is population health management and what data sources drive it?
• Which is a core PBM activity?
• How do employer-sponsored, self-funded plans differ from fully insured plans in terms of risk and data access?
• What is case management and which metrics are commonly monitored?
• What is Utilization Management (UM)?
• Accountable Care Organizations are defined as groups focused on which goals?
• HEOR primarily contributes to what area?
• Utilization management's role in ensuring standards of care is best described as:
• What is the main purpose of a restricted provider network in managed care?
• Which statement best describes typical strategies to address social determinants of health within managed care?
• Managed Care Pharmacy is defined as the use of what to optimize medication outcomes and resource use?
• What is a PPO?
• What are standards of care and their role in utilization management?
• In a DRG-based payment environment, what is the role of prior authorization?
• How do episodic payments differ from per-member-per-month payments?
• Which term describes the gatekeeper model in primary care?
• Managed Care Organizations (Noun) include which of the following?
• How do disease management and case management differ in focus?
• Quality incentives in managed care typically involve which type of payment?
• Which utilization review happens after care?
• What is a copay?
• In a restricted network, which factor is primarily controlled?
• What is data governance and why is it critical in managed care?
• What is the primary purpose of utilization management tools such as pre-certification and discharge planning?
• In capitation arrangements, which statement best describes actuarial soundness?
• Under capitation, what is the purpose of quality safeguards?
• How is actuarial analysis used in pricing a managed care product?
• What is the primary function of risk pools in population health financing?
• What is an Indemnity Plan (Fee-for-Service)?
• Which formulary strategy uses a stepwise approach to drug therapy?
• What describes the health insurance financing model?
• How are social determinants of health (SDoH) addressed by managed care plans?
• Health Maintenance Organization (HMO) is best described as which of the following?
• Which description best defines managed care?
• What is the role of DRGs in Medicare hospital payments?
• Distinguish prospective and concurrent prior authorization with an example of each.
• Which entity is most likely to administer the prescription drug benefit for a health plan?
• Formulary management primarily aims to...
• Which statement about formulary development is accurate?
• The Triple Aim includes which components?
• Which statement best describes step therapy, prior authorization, and formulary in drug benefit management?
• Under capitation, which statement most accurately describes financial risk?
• Formulary is defined as what?
• Which statement about applying social determinants of health (SDoH) in care management is most accurate?
• What is the role of care gap tracking in managed care?
• P&T Committee refers to which group?
• What is a POS Plan?
• Which rebate is based on achieving clinical or utilization targets?
• What is a key outcome of effective use of a Health Information Exchange in care coordination?
• Which utilization review occurs before care and often includes prior authorization?
• Which item is NOT typically considered a component of member services in a managed care plan?
• Capitation is defined as which of the following statements?
• What is the premium in health insurance?
• How do rebates and negotiated discounts influence formulary design and pharmaceutical pricing?
• In managed care, provider consolidation is primarily intended to achieve which outcome?
• Which statement best describes the impact of capitation on incentives for providers?
• Which model requires a PCP referral to see specialists?
• What is the original concept of a Health Maintenance Organization (HMO)?
• Which of the following is NOT a HIPAA safeguard category?
• Pharmacy Benefit Design describes which concept?
• What is the Clinical-Minimum Index used for in managed care?
• What best describes coinsurance?
• Which statement best defines capitation in managed care?
• Which statement best contrasts premiums and out-of-pocket costs in plan design?
• How does telemedicine affect access to care and cost containment when appropriately reimbursed and integrated?
• In CMS-HCC risk scoring, which patients typically yield higher risk scores and payments?
• In a typical managed care contract, which item is NOT usually included as a standard component?
• How is lean management applied to healthcare processes to reduce waste?
• Which statement best describes the role of patient-centered medical homes in coordinating care?
• Managed Care Activities (Verb) include which items?
• Which statement accurately describes the original concept of the HMO?
• The P&T Committee's primary responsibility is to manage what?
• Which formulary tier corresponds to preferred generics (lowest cost)?
• What is the term for post-purchase discounts returned to PBMs or plans?
• Which statement best contrasts fee-for-service with managed care payment incentives?
• Which statement about care coordination in integrated delivery systems is most accurate?
• Which rebate is a fixed or % discount for formulary placement or tier status?
• In managed care contracts, which statement about data sharing is most accurate?
• Which component is used to identify the reasons behind quality issues in a Quality Improvement plan?
• Which statement best describes the primary difference between HMO and PPO in terms of network flexibility and referrals?
• Which mechanism best aligns incentives in a managed care contract with outcomes and efficiency in mind?
• What is modular contracting in managed care?
• What is the purpose of appeals and grievances processes in managed care?
• What is a preferred provider organization (PPO) network and how does it influence payer strategy?
• Which term describes a rebate tied to achieving clinical or utilization targets?
• Within the context of population health management, what is the purpose of risk stratification?
• Which measure is primarily used to evaluate clinical performance in plan evaluations?
• Which of the following describes the complete set of health care outcomes used for evaluation?
• Which lean management tools are commonly applied in healthcare to reduce waste?
• Managed Care Trends 2026 emphasize which shift?
• In coverage determinations, which type of evidence is central to decision-making?
• Which statement best describes the progression of management in the Managed Care Continuum?
• Which statement best describes the difference between an HMO and a PPO in terms of network flexibility and referrals?
• Which statement about value-based contracting is most accurate?
• Which component of the Triple Aim is directly concerned with patient experience?
• Capitated payments incentives: Which statement best describes the incentive effect of capitated payments compared with discounted FFS?
• Which statement best describes network adequacy metrics?
• Which activity is considered part of the core functions of the US healthcare system?
• In managed care payment models, what is the purpose of risk-adjusted payments?
• What is population health management and what are its core activities?
• How do Medicare Advantage plans differ from traditional Medicare in payment structure and care delivery?
• Why is interoperability important in health IT and managed care?