CMCN : ABMCN Certification in Managed Care Nursing Exam

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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?
1. Fee-for-service model
2. 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
Capitation model with shared savings
3. P
Ans
Expl r
prov his
mod are,
ulti
Que
f the
follo nce
with l
1. D a
timel
2. Ig
3. Informing the member that their complaint is unwarranted
4. 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
Que
Whi n and
Affo
1. It
2. It ans
3. It mandated coverage for preventive services without cost-sharing and expanded access to care
4. 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.
Question: 392
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.
stion: 393
ch of the following is a key component of a successful utilization agement program that directly influences patient care decisions?
What is the most critical economic principle that managed care organizations must apply to ensure the sustainability of healthcare delivery in a resource- constrained environment?
1. C
2. P
3. R
4. D
Ans Expl
orga care
deliv susta
Que
Whi man
1. The integration of clinical guidelines and evidence-based practices into the decision-making process
2. A focus solely on cost reduction strategies
3. The exclusion of interdisciplinary collaboration among healthcare providers
4. 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.
Question: 394
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.
stion: 395
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:
1. E
2. L
3. A
4. I
Ans Expl
prov and
impr
Que
Whi are
is ac
1. P
2. Engaged patients are more likely to adhere to treatment plans and utilize preventive services
3. Patient engagement solely focuses on financial aspects of care
4. 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.
Question: 396
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.
stion: 397
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
1. T
2. T
3. T
4. T
Ans
Expl a
duty o
Que
The c h:
1. E ic
status
2. Promoting luxury healthcare services for affluent populations
3. Standardizing treatment protocols across all patient demographics
4. 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.
Question: 398
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.
stion: 399
erm "population health management" refers to:
The principle of "accountable care organizations" (ACOs) in managed care emphasizes:
1. C
outc
2. In es
3. T
4. T
Ans
Expl n
amo
finan are
deliv Que The t
1. The strategy of managing the health of an individual patient
2. The process of managing healthcare costs for high-risk individuals
3. The approach of analyzing health outcomes and health determinants within a specific group to improve care quality and reduce costs
4. 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.
Question: 400
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.
stion: 401
Whi ions
when g
adhe
1. A in
malp
2. N nces
3. P
4. N
Ans
Expl al
liabil stan
Que
In evaluating the effectiveness of telehealth services within a managed care framework, which factor is most critical to assess?
1. The technological literacy of patients
2. Patient health outcomes post-telehealth consultation
3. The geographical distribution of providers
4. 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.
stion: 403
Question: 402
What tate
man
1. It nly.
2. It d
satis
3. It
4. It s.
Ans
Expl nts
and h s and
high
Que
Which of the following best describes the concept of "shared savings" in the context of value-based care arrangements within managed care organizations?
1. A fixed payment amount received by providers for each patient
2. A system that rewards providers based on patient satisfaction scores
3. A penalty system for providers who exceed budgeted costs
4. 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.
stion: 404
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
1. U
2. R
3. C
4. N
Ans
Expl are
costs withi
Question: 405
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?
1. Mediation encourages collaboration and open dialogue.
2. Mediation typically involves a more formal process.
3. Mediation allows for legally binding decisions.
4. 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.
stion: 406
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
Que
Whi man
1. A
2. A
3. A the
healt
4. A
Ans
Expl igate
the c that
patients receive the services they need in a timely manner.
Question: 407
In the context of managed care, what does the acronym "PCMH" stand for, and what is its primary goal?
1. Preferred Care Management Hub; to reduce administrative costs
2. Patient-Centered Medical Home; to provide coordinated, comprehensive care
3. 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.
stion: 408
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
Que
care, eval
1. E
2. P
3. A
4. 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.
Question: 409
Which of the following best describes the concept of "value-based care" in relation to quality management in a managed care setting?
1. An approach that prioritizes patient outcomes and satisfaction over the volume of services delivered
2. A focus on maximizing the volume of services provided to patients
3. 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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