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Healthcare Management: An Introduction Questions 86–90 (page: 19)

Updated On: 10-Feb-2026

In claims administration terminology, a claims investigation is correctly defined as the process of

  1. reporting management information about services provided each time a patient visits a provider for purposes of analyzing utilization and provider practice patterns
  2. obtaining all the information necessary to determine the appropriate amount to pay on a given claim
  3. routinely reviewing and processing a claim for either payment or denial
  4. assigning to each diagnosis or treatment reported on a claim special codes that briefly and specifically describe each diagnosis and treatment

Answer(s): B



In health plan terminology, demand management, as used by health plans, can best be described as:

  1. an evaluation of the medical necessity, efficiency, and/or appropriateness of healthcare services and treatment plans for a given patient
  2. a series of strategies designed to reduce plan members' needs to utilize healthcare services by encouraging preventive care, wellness, member self-care, and appropriate use of healthcare services
  3. a technique that prevents a provider who is being reimbursed under a fee schedule arrangement from billing a plan member for any fees that exceed the maximum fee reimbursed by the plan
  4. a system of identifying plan members with special healthcare needs, developing a healthcare strategy to meet those needs, and coordinating and monitoring the care

Answer(s): B



In large health plans, management functions such as provider recruiting, credentialing, contracting, provider service, and performance management for providers are typically the responsibility of the

  1. chief executive officer (CEO)
  2. network management director
  3. board of directors
  4. director of operations

Answer(s): B



In most cases, medical errors are caused by breakdowns in the healthcare system rather than by provider mistakes.

  1. True
  2. False

Answer(s): A



In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known

  1. dual choice
  2. cost shifting
  3. accreditation
  4. defensive medicine

Answer(s): B



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