ABPS Healthcare Systems & Administration 4 — Questions and Answers
Question 1: What is the purpose of a formulary in a health insurance plan?
- To define network hospitals available to members
- To list covered prescription drugs and their cost-sharing tiers (Correct answer)
- To outline prior authorization requirements for inpatient stays
- To establish co-payment amounts for office visits
Correct answer: To list covered prescription drugs and their cost-sharing tiers
A formulary is a tiered list of covered medications that determines member cost-sharing and guides prescribing decisions within a health plan.
Question 2: Which model of care delivery places a team of healthcare professionals responsible for all of a patient's care needs across settings?
- Episodic care model
- Patient-Centered Medical Home (PCMH) (Correct answer)
- Concierge medicine model
- Fee-for-service model
Correct answer: Patient-Centered Medical Home (PCMH)
The PCMH model emphasizes comprehensive, coordinated, team-based care with a personal physician leading a care team across all health domains.
Question 3: A 'sentinel event' in hospital quality management is defined as:
- Any adverse event that occurs on a night or weekend shift
- An unexpected occurrence involving death or serious physical or psychological injury (Correct answer)
- A complaint filed by a patient against a nurse
- A billing discrepancy identified during an audit
Correct answer: An unexpected occurrence involving death or serious physical or psychological injury
The Joint Commission defines a sentinel event as an unexpected incident causing death or serious harm, requiring immediate root cause analysis.
Question 4: Under value-based purchasing (VBP), hospital payments are adjusted based on:
- Total number of beds and available ICU capacity
- Performance on quality and patient experience measures (Correct answer)
- Geographic location and labor market costs only
- Physician specialty mix within the facility
Correct answer: Performance on quality and patient experience measures
CMS's Hospital VBP program ties a portion of inpatient payments to performance on measures of clinical outcomes, safety, efficiency, and patient experience.
Question 5: Which of the following is the primary function of a utilization review committee in a hospital?
- Reviewing physician malpractice claims and settlements
- Evaluating the appropriateness and medical necessity of services provided (Correct answer)
- Credentialing new medical staff members
- Auditing financial statements for regulatory compliance
Correct answer: Evaluating the appropriateness and medical necessity of services provided
Utilization review involves evaluating whether the services rendered are medically necessary and appropriate, preventing overuse and supporting payer authorization decisions.
Question 6: The concept of 'bundled payments' in healthcare reimbursement means:
- Paying separately for each individual service within an episode of care
- A single payment covering all services related to a specific treatment episode (Correct answer)
- Combining primary and specialty care billing under one provider number
- Grouping multiple patients' claims together for a single insurer payment
Correct answer: A single payment covering all services related to a specific treatment episode
Bundled payments provide a single reimbursement for all services (hospital, physician, post-acute) related to a defined episode, incentivizing coordination and efficiency.
Question 7: Which law established the Children's Health Insurance Program (CHIP) to extend coverage to uninsured children in families with incomes too high for Medicaid?
- Affordable Care Act (ACA) of 2010
- Balanced Budget Act of 1997 (Correct answer)
- Social Security Amendments of 1965
- HITECH Act of 2009
Correct answer: Balanced Budget Act of 1997
CHIP was created by the Balanced Budget Act of 1997 as Title XXI of the Social Security Act, providing states with federal funds to cover low-income children not eligible for Medicaid.
ABPS Healthcare Systems & Administration 4
What is the purpose of a formulary in a health insurance plan?