CMOM Module 5 Questions
with Answers
MCO Coordinator functions - Answer-1) Patient training and education
2)HMO intermediary
3)Hospitalization approvals and discharge planning
4) coordinating referrals
5)patient satisfaction surveys
6)coordinating with physician in utilization review committee
7)coordinating quality assurance data needed by MCO or other regulatory agency
Utilization review committee - Answer-should be used to review all cases which may
need to be referred to a specialist, where surgery is anticipated or where testing has
failed to find the cause of the problem
Utilization Coordinator functions - Answer-1)Referral systems control
2)hospitalization controls
3)emergency care controls
4)hospital and referral physician contracts and relations
5)monitoring ongoing care
6)monitoring care for non-covered or non-authorized services
7)Utilization control committees in medical groups, IPAs or hospitals
8)patient education and counseling
9)patient actions required by HMO in utilization control
Patient education - Answer-involves a variety of programs aimed at preventative care,
maintaining health through better nutrition, exercises and other techniques with can help
to promote better health.
Chronic Illness programs - Answer-education for those with chronic illnesses (such as
diabetes and hypertension) that includes teaching the patient how to eat right, use
medication properly and know when to visit the physician for a check up
Prenatal Classes - Answer-another type of educational program during pregnancy that
is intended to prevent acute problems and aid in self-monitoring
Factors behind development of the Affordable Care Act - Answer-1)Rising healthcare
costs per capita
2)an increasing number of individuals living with chronic conditions
, 3)a proportions of the population that remains uninsured due to cost, pre-existing
conditions and other factors
Accountable Care Organization - Answer-a healthcare organization that agrees to be
accountable for the quality, cost and overall care of traditional fee for service medicare
beneficiaries assigned to it. AKA 'medical neighborhood'
Types of ACO (Accountable Care Organization) - Answer-Medicare Shared Savings
Program
Advanced Payment ACO Model
Pioneer ACO Model
Patient Centered Medical Homes (PCMH) - Answer-involve coordination between
providers, particularly at the primary care level, and a variety of healthcare entities in
order to create a more integrated system of care for the patient
A PCMH (patient centered medical home) contains the following characteristics -
Answer-Personal physician
physician directed medical practice
whole person orientation
care is coordinated and/or integrated
emphasis on quality and safety
Credentialing - Answer-verifies that a physician meets standards through the review of
license, experience, certification, education, training, malpractice and adverse clinical
occurrences, clinical judgement and character via investigation and observation
Privileging - Answer-Defines a physician's scope of practice and the clinical services he
or she may provide
Council for Affordable Quality HealthCare (CAQH) - Answer-not-for-profit collaborative
alliance of health plans and networks which offers a standardized credentialing process
PECOS (Provider Enrollment, Chain and Ownership System) - Answer-Medicare's
Internet Based provider enrollment
NCQ (National Committee for Quality Assurance) - Answer-used to limit its accreditation
to HMOs, but has recently expanded to accredit CVOs, Behavioral Managed Health
Care organizations and Physician Organizations
JCAHO (Joint Commission on Accreditation of Healthcare Organizations - Answer-
started out as a hospital accreditation org, accredits all types of MCOs through its health
care network accreditation program. They Also have a specific set of standards for
PPOs and Managed Behavioral Health Care Orgs
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