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CMCN : ABMCN Certification in Managed Care Nursing Exam
Nursing CMCN Questions & Answers
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ABMCN Certification in Managed Care Nursing
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In a managed care setting, which of the following models best aligns incentives for providers to deliver high-quality care while controlling costs?
Fee-for-service model
Volume-based reimbursement
er diem payment model wer: C
anation: The capitation model with shared savings aligns incentives fo iders by rewarding them for delivering high-quality care efficiently. T el encourages providers to focus on population health and preventive c mately controlling costs while improving patient outcomes.
stion: 389
When a member files a grievance in a managed care organization, which o wing steps is most critical in the grievance process to ensure complia egal and regulatory standards?
ocumenting the grievance and conducting a thorough investigation in y manner
noring the grievance until it escalates
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Informing the member that their complaint is unwarranted
Resolving the grievance without any documentation Answer: A
Explanation: It is critical to document the grievance and conduct a thorough investigation in a timely manner to ensure compliance with legal and regulatory
Question: 390
Which of the following strategies is commonly employed by managed care organizations to control pharmaceutical costs?
ncouraging patients to use only generic medications without exception mplementing formulary restrictions and prior authorization for high-co
roviding financial incentives for patients to choose brand-name drugs wer: C
anation: Managed care organizations often use formulary restrictions a authorization to manage and control costs associated with high-price cations.
stion: 391
ch of the following describes the significance of the "Patient Protectio rdable Care Act" (ACA) for managed care organizations?
eliminated all managed care plans
restricted the number of patients that could enroll in managed care pl
Allowing unlimited access to all medications regardless of cost E s I st drugs P Ans Expl nd prior d medi Whi n and Affo It It ans It mandated coverage for preventive services without cost-sharing and expanded access to care It reduced the regulatory requirements for managed care organizations Answer: C for preventive services without cost-sharing, positively impacting managed care organizations and their members. ost Efficiency rice Regulation esource Allocation emand Forecasting wer: C anation: Effective Resource Allocation is crucial for managed care nizations to optimize the use of limited resources, ensuring that health ery meets population health needs while maintaining financial inability. ch of the following is a key component of a successful utilization agement program that directly influences patient care decisions? C P R D Ans Expl orga care deliv susta Whi man The integration of clinical guidelines and evidence-based practices into the decision-making process A focus solely on cost reduction strategies The exclusion of interdisciplinary collaboration among healthcare providers A centralized approach that disregards individual patient circumstances Explanation: Integrating clinical guidelines and evidence-based practices into utilization management decisions helps ensure that patient care is appropriate and effective while balancing cost considerations. valuate the quality of care provided by hospitals imit patient access to specialized treatment ssess the appropriateness of services provided to patients ncrease the volume of services billed to insurance wer: C anation: Utilization Review (UR) aims to assess whether the services ided to patients are necessary and appropriate, helping to control costs ove the quality of care. ch of the following statements about patient engagement in managed c curate? atient engagement is not a priority in managed care settings The primary purpose of a Utilization Review (UR) in managed care is to: E L A I Ans Expl prov and impr Whi are is ac P Engaged patients are more likely to adhere to treatment plans and utilize preventive services Patient engagement solely focuses on financial aspects of care It is primarily the responsibility of healthcare providers without patient involvement Explanation: Patient engagement is critical in managed care, as engaged individuals are more likely to adhere to treatment and utilize preventive services, leading to better health outcomes. edure. What must be demonstrated for a successful malpractice claim nst the nurse? hat the nurse had a duty of care hat the nurse acted in good faith hat the patient signed informed consent hat the nurse followed hospital policy wer: A anation: To establish malpractice, it must be shown that the nurse had f care to the patient, which was breached, leading to harm. oncept of "health equity" in managed care is primarily concerned wit nsuring equal access to healthcare services regardless of socioeconom A nurse is accused of negligence after a patient suffers complications from a proc agai T T T T Ans Expl a duty o The c h: E ic status Promoting luxury healthcare services for affluent populations Standardizing treatment protocols across all patient demographics Focusing solely on the financial performance of healthcare providers Answer: A Explanation: Health equity is an essential principle in managed care, emphasizing the need for equal access to healthcare services for all individuals, regardless of their socioeconomic status or other barriers. ollaboration among providers to coordinate care and improve health omes while sharing financial risks and rewards dividual provider autonomy without accountability for patient outcom he focus on hospital-based care only he limitation of services to reduce overall healthcare spending wer: A anation: Accountable care organizations (ACOs) promote collaboratio ng providers to coordinate care, improve patient outcomes, and share cial risks and rewards, ensuring a more integrated approach to healthc ery. erm "population health management" refers to: The principle of "accountable care organizations" (ACOs) in managed care emphasizes: C outc In es T T Ans Expl n amo finan are deliv Que The t The strategy of managing the health of an individual patient The process of managing healthcare costs for high-risk individuals The approach of analyzing health outcomes and health determinants within a specific group to improve care quality and reduce costs The implementation of disease-specific protocols across all patient populations Answer: C Explanation: Population health management focuses on improving health outcomes for a specific population by analyzing data and addressing health determinants, ultimately aiming to enhance care quality and reduce costs. ch of the following best captures the legal implications of a nurse's act providing care in a managed care environment, particularly regardin rence to established protocols? dhering to established protocols can protect nurses from legal liability ractice cases urses are free to deviate from established protocols without conseque rotocols are optional guidelines with no legal bearing urses are solely responsible for creating their own care protocols wer: A anation: Adhering to established protocols can protect nurses from leg ity in malpractice cases, as it demonstrates compliance with accepted dards of care. when g adhe A in malp N nces P N Ans Expl al liabil stan In evaluating the effectiveness of telehealth services within a managed care framework, which factor is most critical to assess? The technological literacy of patients Patient health outcomes post-telehealth consultation The geographical distribution of providers The number of telehealth visits conducted Answer: B Explanation: Assessing patient health outcomes post-telehealth consultation is critical for evaluating the effectiveness of telehealth services, as it provides direct insight into the quality and impact of care delivered remotely. is the significance of patient-centered care in the context of disease s agement programs? shifts the focus away from clinical outcomes to patient preferences o fosters a collaborative approach that enhances treatment adherence an faction. solely emphasizes the use of technology in managing patient data. disregards the importance of clinical guidelines in treatment decision wer: B anation: Patient-centered care emphasizes collaboration between patie ealthcare providers, leading to improved adherence to treatment plan er patient satisfaction. Question: 402 What tate man It nly. It d satis It It s. Ans Expl nts and h s and high Which of the following best describes the concept of "shared savings" in the context of value-based care arrangements within managed care organizations? A fixed payment amount received by providers for each patient A system that rewards providers based on patient satisfaction scores A penalty system for providers who exceed budgeted costs A financial incentive model where providers share in the savings generated by reducing healthcare costs while maintaining quality Answer: D Explanation: Shared savings arrangements incentivize providers to reduce costs while maintaining or improving quality, allowing them to share in the financial benefits of efficient care delivery. ch of the following terms refers to the practice of managing healthcare by limiting the types of services and providers available to a patient n a health plan? tilization review isk adjustment are coordination etwork restriction wer: D anation: Network restriction refers to the practice of managing healthc by limiting the types of services and providers available to a patient n a health plan, affecting patient choice. Que Whi costs withi U R C N Ans Expl are costs withi A patient is dissatisfied with their treatment and seeks to resolve the issue through an alternative dispute resolution (ADR) process. Which of the following best describes the advantages of mediation over arbitration in this context? Mediation encourages collaboration and open dialogue. Mediation typically involves a more formal process. Mediation allows for legally binding decisions. Mediation is less costly than litigation but not arbitration. Answer: A es to reach mutually agreeable solutions, whereas arbitration often res inding decision made by a third party. ch of the following best describes the role of a nurse navigator in a aged care setting? nurse who provides administrative support to physicians nurse who focuses solely on conducting health assessments nurse responsible for coordinating care and assisting patients through hcare system nurse who manages insurance claims for patients wer: C anation: A nurse navigator plays a critical role in helping patients nav omplexities of the healthcare system, coordinating care, and ensuring Explanation: Mediation encourages collaboration and open dialogue, allowing parti ults in a b Whi man A A A the healt A Ans Expl igate the c that patients receive the services they need in a timely manner. In the context of managed care, what does the acronym "PCMH" stand for, and what is its primary goal? Preferred Care Management Hub; to reduce administrative costs Patient-Centered Medical Home; to provide coordinated, comprehensive care Primary Care Management Health; to increase the number of primary care providers anation: PCMH stands for Patient-Centered Medical Home, which ai ide coordinated and comprehensive care to improve patient outcomes faction. When assessing the impact of social determinants of health (SDOH) on pa which of the following factors should be prioritized in managed care uations? conomic stability and access to resources atient health insurance status vailability of healthcare providers in the area requency of healthcare visits wer: A Patient Care Management Health; to enhance patient satisfaction Answer: B Expl ms to prov and satis care, eval E P A F Ans tient Explanation: Economic stability and access to resources are critical factors to prioritize when assessing the impact of social determinants of health (SDOH) on patient care, as they significantly influence health outcomes and access to necessary services. Which of the following best describes the concept of "value-based care" in relation to quality management in a managed care setting? An approach that prioritizes patient outcomes and satisfaction over the volume of services delivered A focus on maximizing the volume of services provided to patients A system that emphasizes cost-cutting measures without regard for quality wer: A anation: Value-based care emphasizes prioritizing patient outcomes a faction, ensuring that healthcare delivery is centered around the qualit ather than the quantity of services provided. A model that relies on financial incentives for providers to increase service usage Ans Expl nd satis y of care r
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