Operational Excellence & Efficiency Flashcards

A care management program transitions from telephonic to embedded care managers co-located in primary care practices. The PRIMARY operational benefit of this model is:

Answer: Improved access to real-time clinical information and warm handoffs at point of care

Embedded care managers gain direct access to the clinical team, patient records, and real-time patient encounters, enabling immediate care coordination and seamless transitions.

Which data source provides care managers with the most comprehensive view of a member's utilization across all settings?

Answer: Claims data aggregated across medical, pharmacy, and behavioral health

Aggregated claims data spanning medical, pharmacy, and behavioral health provides a complete longitudinal picture of all services a member has received across all providers and settings.

A care management supervisor observes that one team member consistently achieves significantly higher engagement rates than peers. The BEST operational approach is to:

Answer: Conduct a structured analysis of the high performer's techniques and spread them to the team

Analyzing and spreading high-performer practices is a fundamental continuous improvement principle that turns individual success into systemic operational improvement.

Under CMS's Chronic Care Management (CCM) billing code (99490), a key operational requirement is that the care manager must document at least how many minutes of care coordination time per month?

Answer: 20 minutes

CPT code 99490 requires a minimum of 20 minutes of non-face-to-face care management time per calendar month to bill for chronic care management services.

A care management team is implementing a predictive analytics tool to identify high-risk members. The MOST important validation step before operational deployment is:

Answer: Testing the model's predictive accuracy against the organization's own population data

Predictive models trained on external populations may not generalize accurately; validating against local population data ensures the model identifies truly high-risk members in that specific context.

In a care management program, which operational indicator BEST signals that the population stratification model needs to be recalibrated?

Answer: A high proportion of members in the 'low-risk' tier experience unexpected hospitalizations

Frequent unexpected hospitalizations among low-risk members indicates the stratification model is miscategorizing members who actually need intervention, signaling model failure.

An integrated care management program serving members with co-occurring medical and behavioral health conditions should PRIMARILY be designed around which operational principle?

Answer: Coordinating medical and behavioral health services within a unified, person-centered care plan

Integrated care management addresses the bidirectional relationship between physical and behavioral health through a unified care plan, preventing fragmented care that fails to address the whole person.