Utilization Management Review Test

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Quizzes Created: 5 | Total Attempts: 5,889
Questions: 17 | Attempts: 1,089

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Management Quizzes & Trivia

Test your knowledge on material read for Utilization Management information.


Questions and Answers
  • 1. 

    Medicare came into existence in 1965 as an amendment to the Social Security Act .

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Medicare was indeed established in 1965 as an amendment to the Social Security Act. This act was passed by the U.S. government to provide health insurance coverage for individuals aged 65 and older, as well as for younger individuals with certain disabilities. Medicare is a federal program that helps to ensure that older Americans have access to affordable healthcare services and coverage.

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  • 2. 

     The primary responsibilities of the UM/UR Nurse include which of the following…

    • A.

      Enforcing DRG rules

    • B.

      Evaluate medical necessity

    • C.

      Evaluate appropriatenss of care

    • D.

      Both B & C

    Correct Answer
    D. Both B & C
    Explanation
    The primary responsibilities of the UM/UR Nurse include evaluating medical necessity and evaluating the appropriateness of care. This means that the nurse is responsible for determining if the medical procedures or treatments being provided to a patient are necessary and if they are being administered in the most appropriate manner. This involves reviewing medical records, consulting with healthcare providers, and making recommendations or decisions regarding the patient's care. The nurse also plays a role in ensuring that healthcare resources are used efficiently and effectively.

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  • 3. 

     Mr. H. was referred by his PCP to an Orthopedic Surgeon for evaluation of worsening right hip pain. The surgeon has recommended a right total arthroplasty.  What type of review will be performed prior to approval of this procedure?

    • A.

      Admission

    • B.

      Preadmission

    • C.

      Concurrent

    • D.

      Contiued Stay

    Correct Answer
    B. Preadmission
    Explanation
    Prior to the approval of the right total arthroplasty procedure, a preadmission review will be performed. This review is conducted to assess the medical necessity and appropriateness of the procedure before the patient is admitted to the hospital. It ensures that the recommended procedure is necessary and meets the criteria for coverage by the insurance provider.

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  • 4. 

    UM is effective only in an enviornment of complete objectivity which is enhanced by the use of accepted severity of illness and intensity of service criteria.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    UM stands for Utilization Management, which is a process used by healthcare organizations to ensure that medical services are appropriate and necessary. This process relies on objective criteria, such as severity of illness and intensity of service, to determine the appropriateness of medical interventions. Therefore, UM is effective only in an environment of complete objectivity, where decisions are based on these accepted criteria. This statement suggests that without objectivity and the use of these criteria, the effectiveness of UM may be compromised. Hence, the correct answer is true.

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  • 5. 

    When counting the days for length of stay it is important to remember not to count:

    • A.

      Day of admission

    • B.

      Day of discharge

    • C.

      Day of admission and day of discharge

    • D.

      Count all days including admission and discharge days

    Correct Answer
    B. Day of discharge
    Explanation
    When counting the length of stay, it is important not to include the day of discharge. This is because the patient is considered to have stayed for the entire day on the day of discharge, so it is not counted separately.

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  • 6. 

    The goal of WellMed's UM department is to ensure the delivery of the services in a quality oriented, timely, medcally appropriate, and the cost efficient manner for the health plan's membership.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    The statement is true because the goal of WellMed's UM (Utilization Management) department is indeed to ensure the delivery of services in a quality-oriented, timely, medically appropriate, and cost-efficient manner for the health plan's membership. This means that the department focuses on managing and coordinating healthcare resources to ensure that patients receive the right care, at the right time, and in the most efficient and effective way possible.

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  • 7. 

    The UM Nurse will base their decision on:

    • A.

      Their opinion of need

    • B.

      Standardized objective criteria

    • C.

      The cost involved

    • D.

      All of the above

    Correct Answer
    B. Standardized objective criteria
    Explanation
    The UM Nurse will base their decision on standardized objective criteria. This means that their decision will not be influenced by personal opinions or the cost involved. Instead, they will use a set of predetermined guidelines or criteria to determine the appropriate course of action. This ensures that the decision-making process is fair and consistent, and that the focus remains on providing the best possible care for the patient.

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  • 8. 

    Everyone over the age of 65 are automatically eligible for Medicare.

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    The statement is false because not everyone over the age of 65 is automatically eligible for Medicare. While most individuals aged 65 and older are eligible for Medicare, there are certain eligibility requirements that need to be met, such as being a U.S. citizen or a legal permanent resident for at least five years. Additionally, individuals who have not paid Medicare taxes for a certain amount of time may have to pay premiums for certain parts of Medicare. Therefore, automatic eligibility for Medicare is not guaranteed for everyone over the age of 65.

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  • 9. 

    All members if Medicare Advantage Plans receive coverage at least equal to that of traditional Medicare.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Medicare Advantage Plans, also known as Part C plans, are offered by private insurance companies approved by Medicare. These plans provide all the benefits of traditional Medicare (Part A and Part B) and often include additional benefits such as prescription drug coverage, dental, vision, and hearing services. Therefore, all members of Medicare Advantage Plans receive coverage at least equal to that of traditional Medicare.

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  • 10. 

    After meeting the Medicare Part B deductible, the patient is responsible for how much of the remaining bill?

    • A.

      10%

    • B.

      20%

    • C.

      25%

    • D.

      0%

    Correct Answer
    B. 20%
    Explanation
    After meeting the Medicare Part B deductible, the patient is responsible for 20% of the remaining bill. This means that Medicare will cover 80% of the costs, and the patient will be responsible for paying the remaining 20%.

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  • 11. 

    CMS depends on hospitals to monitor the challenge of controlling readmissions.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    The statement is true because CMS (Centers for Medicare and Medicaid Services) relies on hospitals to effectively manage and address the issue of readmissions. Readmissions occur when a patient is admitted to the hospital again within a certain timeframe after being discharged. These readmissions can be costly and indicate potential problems with the quality of care provided. CMS has implemented various programs and initiatives to reduce readmissions, and hospitals play a crucial role in monitoring and implementing strategies to control readmission rates.

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  • 12. 

    Provides a comprehensive set of health benefits on a prepaid basis directly to its enrollees through designated physicans and hospitals.

    • A.

      Preferred Provider Organization (PPO)

    • B.

      Health Maintenance Organization (HMO)

    • C.

      Point of Service Plans (POS)

    • D.

      Traditional Indemnity Plan (TIP)

    Correct Answer
    B. Health Maintenance Organization (HMO)
    Explanation
    An HMO provides a comprehensive set of health benefits on a prepaid basis directly to its enrollees through designated physicians and hospitals. This means that individuals who are enrolled in an HMO plan have access to a network of healthcare providers who have agreed to provide services at a lower cost. HMOs typically require individuals to choose a primary care physician who acts as a gatekeeper for accessing specialized care. This helps to control costs and ensure that individuals receive coordinated and preventive care.

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  • 13. 

    This organization's role is to regulate and supervise HMO's

    • A.

      Utilization Review Accreditation Commission

    • B.

      Centers for Medicare & Medicaid Servies

    • C.

      National Committee for Quality Assurance

    • D.

      Department of Affordable Health

    Correct Answer
    C. National Committee for Quality Assurance
    Explanation
    The National Committee for Quality Assurance (NCQA) is the correct answer because it is an organization that is responsible for regulating and supervising Health Maintenance Organizations (HMOs). NCQA sets standards and measures the quality of healthcare provided by HMOs, ensuring that they meet certain criteria and provide high-quality care to their members. They also accredit and certify HMOs based on their performance and adherence to these standards.

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  • 14. 

    If a request for service is denied it is the responsibility of the UM/UR nurse to inform the patient and the requesting physician of their right to appeal.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    The responsibility of the UM/UR nurse is to inform the patient and the requesting physician about their right to appeal if a request for service is denied. This ensures that both parties are aware of their options and can take appropriate action if they disagree with the denial. By informing them of their right to appeal, the UM/UR nurse empowers the patient and the requesting physician to advocate for themselves and seek a reconsideration of the denied request.

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  • 15. 

    Nurse Reviewers play a major role in assuring the effective use of healthcare dollars in America.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Nurse Reviewers are responsible for evaluating and reviewing healthcare services to ensure that they are necessary, appropriate, and cost-effective. Their role is crucial in controlling healthcare costs and ensuring that resources are used efficiently. By carefully reviewing medical records, treatment plans, and insurance claims, Nurse Reviewers help to prevent unnecessary procedures, reduce healthcare expenses, and promote the effective use of healthcare dollars. Therefore, it can be concluded that Nurse Reviewers play a major role in assuring the effective use of healthcare dollars in America.

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  • Current Version
  • Mar 22, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Jun 12, 2013
    Quiz Created by
    Healthright
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