1. (a) Most self-management education focuses on the lower three levels of Bloom's Taxonomy of Educational Objectives: 1) knowledge, 2) understanding, and 3) application. If patients are unable to answer questions, it may be that the questions being asked are at a level that is too high for them. A simpler question at a lower level will usually help. For example, if patients seemed unable to discuss how to prevent hypoglycemia, then a question at the understanding (application) level would be appropriate. For example, What have you learned about low blood sugar reactions? Conversely, if patients can answer questions too easily, then more complex questions at a higher level of the taxonomy are appropriate.

2. (d) All. Each protocol developed, pursuant to the collaborative drug therapy management agreement, shall contain detailed direction concerning the actions that the pharmacist may perform for that patient. The protocol shall include, but need not be limited to, (1) the specific drug or drugs to be managed by the pharmacist, (2) the terms and conditions under which drug therapy may be implemented, modified or discontinued, (3) the conditions and events upon which the pharmacist is required to notify the physician, and (4) the laboratory tests that may be ordered. All activities performed by the pharmacist in conjunction with the protocol shall be documented in the patient's medical record. The pharmacist shall report at least every thirty days to the physician regarding the patient's drug therapy management.

3. (b) The partial supply of Schedule II controlled drugs is only permitted after 72 hours if the patient resides in an LTCF or the patient is diagnosed as terminally ill.

(d) The principal components of a Pharmacy Benefit Management (PBM) program are:
1. A legally enforceable benefit design contract that outlines covered and excluded benefits.
2. A defined physician provider network under contract with the health plan.
3. A defined pharmacy provider network under contract with the health plan or PBM. 4. A community pharmacy network with point-of-sale (POS) computer adjudication system.
5. A drug formulary.
6. A mandatory generic substitution program.
7. Pharmaceutical manufacturer discounts or rebates.
8. A patient prescription co-payment.
9. Retrospective drug utilization review (DUR).
10. Drug formulary conversion.
11. Compliance improvement.
12. Disease management program.

4. (d) The principal components of a Pharmacy Benefit Management (PBM) program are:

1. A legally enforceable benefit design contract that outlines covered and excluded benefits.
2. A defined physician provider network under contract with the health plan.
3. A defined pharmacy provider network under contract with the health plan or PBM.
4. A community pharmacy network with point-of-sale (POS) computer adjudication system.
5. A drug formulary.
6. A mandatory generic substitution program.
7. Pharmaceutical manufacturer discounts or rebates.
8. A patient prescription co-payment.
9. Retrospective drug utilization review (DUR).
10. Drug formulary conversion.
11. Compliance improvement.
12. Disease management program.

5.(d) All. Health Plan Employer Data and Information Set (HEDIS) is a set of standardized measures of health plan performance. HEDIS allows comparisons between plans on quality, access and patient satisfaction membership and utilization financial information and health plan management. HEDIS was developed by employers, HMOs, and the National Committee for Quality Assurance (NCQA). There are eight major categories included in HEDIS:.1. Effectiveness of care.
2. Access and availability of care.
3. Satisfaction with experience of care.
4. Health plan stability.
5. Use of services.
6. Cost of care.
7. Informed health services.
8. Health plan descriptive data.

6. (b) General member satisfaction can be measured by qualitative and quantitative assessment of telephone inquiries on help lines. Help lines assist the plan member to resolve inquiries related to pharmacy benefits. Automatic call distributor (ACD) measures the help line performance for PBM. The following industry standards are verified or measured:.
1. Calls received.
2. Calls answered.
3. Calls abandoned.
4. Abandoned rate.
5. Percent of calls answered within 30 seconds.
6. Average speed of answer.
7. Average talk time.

7. (d) Atomoxetine (Strattera) is the first and only non-stimulant medication approved by the US Food and Drug Administration (FDA) for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children, adolescents, and adults. It is a norepinephrine reuptake inhibitor, a class of ADHD treatment that works differently from the other ADHD medications available. All other choices are controlled substances that can be diverted or abused.

8. (a) Reactively. States use different approaches to analyzing the prescription information they receive. A few states routinely analyze prescription data collected by the PDMPs to identify individuals, physicians, or pharmacies that have unusual use, prescribing, or dispensing patterns that may suggest potential drug diversion, abuse, or doctor shopping. States refer to this as a proactive approach to identifying drug diversion. Trend analyses are shared with appropriate entities, such as law enforcement, practitioners, and regulatory and licensing boards.
In contrast, most state PDMPs generally use the prescription data to respond to requests for information. These requests may come from physicians or from law enforcement or state officials based on leads about potential instances of diversion. According to state program officials, most PDMPs operate in the latter fashion, which is called reactively, because of the increased amount of resources required to operate a proactive system.

9. (b) Medigap usually covers the Part A coinsurance and for the cost of 365 extra days of hospital care during a patient's lifetime after Medicare coverage ends. It also covers the Part B coinsurance (generally 20% of the Medicare-approved payment amount) and foreign travel emergency. In addition to these, some plans may cover limited prescription drug benefits and offer preventive care. .Medigap policy does not cover:
.1. Long-term care.
2. Vision or dental care.
3. Hearing aids.
4. Private-duty nursing.
5. Unlimited prescription drugs.

10. a Current DUR procedures in most healthcare plans focus on product-centered utilization trends. For example, at the time of analyzing a DUR study most of the attention is given to drug products in terms of dollar costs and total unit dispensing rate. This sometimes may result in unwarranted physician inquiries and intervention that are not clinically significant. For example, if a patient is taking a proton pump inhibitor for several months, the computer will mark the patient profile to be reviewed for DUR under the category of exceeds appropriate duration of use. The DUR performer in this type of study does not look in depth for the past patient history of severe erosive esophagitis or gastric surgery.

In most cases, the drug has been used appropriately, however the person performing the DUR has been forced into product-centered DUR without considering the patient past history or clinical status. Switching to patient-centered DUR study provides more accurate clinical status of the patient and helps in controlling healthcare cost as well as healthcare related services more efficiently. In this type of study, importance is primarily given to inappropriate utilization of medications and screening of targeted patient-population. For example, patients who are elderly with prior history of bone fractures and falls may be screened for drugs that may potentially cause additional falls and fractures or for drugs that may adversely affect bone mass index. This may include excessive or inappropriate use of sedatives or benzodiazepines, which may cause additional falls.

11. (a) The following coding systems, ICD-9-CM, CPT-4 , and HCPCS, were adopted as standard code sets under the Health Insurance Portability and Accountability Act (HIPAA). Effective October 16, 2003, all covered entities are required to use these national coding systems.
.1. ICD-9-CM is the official system of assigning codes to diagnoses and hospital procedures in the United States. Volumes 1 and 2 comprise diagnostic codes, and Volume 3 lists certain hospital procedure codes. ICD-9-CM is maintained jointly by the National Centers for Health Statistics and the Centers for Medicare and Medicaid Services as part of the ICD-9-CM Maintenance Committee. ICD-9-CM is modified annually to accommodate new terminology and procedures, and to update outdated nomenclature. ICD-9-CM will eventually be replaced by ICD-10-CM (diagnostic codes) and ICD-10-PCS (hospital procedure codes).

2. CPT is a systematic coding system for reporting medical services and procedures performed by physicians. CPT is maintained by the American Medical Association and is modified every year. Revisions are usually effective for dates of service on or after January 1 of each year. CPT also represents Level 1 of the Healthcare Common Procedure Coding System.
3. The Healthcare Common Procedure Coding System (pronounced Thick-picks) was originally created for use under the Medicare program. Today, HCPCS is used by virtually every payer in the United States.

12. (d) All. Medical providers who bill Medicare, Medicaid, and other Government programs use a standardized system of numerical codes for patient services. In this way, insurers and the Government do not have to work out what services were provided from numerous records or from thousands of different types of coding or billing systems. Misuse of these standardized codes to obtain more money than is allowed by law is commonly termed "UPCODING" or "UPCHARGING."
Each Medicare billing code is tied to a particular group of services and will eventually result in a reimbursement to the physician or other provider (hospital, psychologist, chiropractor, etc.) based upon the code entered by the provider. Providers have financial incentives to "upcode" or increase the bill by exaggerating or even falsely representing what medical conditions were present and what services were provided.
For example, when a 2-minute visit for diagnosis and treatment of an upper respiratory condition (i.e. a cold without complications) is "upcharged" from a very low reimbursement rate code by intentionally using codes for a more serious ailment. Thus, the "URI" or "upper respiratory infection" diagnosis is altered to indicate that the patient was suffering from a more severe bronchitis and sinus infection, with some breathing impairment requiring nebulizer treatment, and the patient required a full 1-hour office visit. In either case, whether the additional services billed were not even provided or if provided but not medically needed, a fraudulent "upcharge" occurs.
Churning occurs when a physician provides a service to a patient more frequently than is necessary for the purpose of billing for more services. For example, a psychiatrist may require more sessions with the patient than are recommended for the condition.
Unbundling or fragmentation occurs when a physician bills separately for services that are normally reported as one service. Medicare and Medicaid often have special reimbursement rates for a group of procedures commonly done together, such as typical blood test panels by clinical laboratories. Some health care providers seeking to increase profits will "unbundle" the tests and bill separately for each component of the group, which totals more than the special reimbursement rates.

. 13. (d) A Schedule II controlled drug cannot be filled in partial amounts unless the pharmacist is out of stock of the drug. A pharmacist may dispense partial amounts of a drug if requested by the patient, but cannot fill the remaining without a new prescription. In the case of when a pharmacist is out of stock of a drug and fills a partial supply of the drug, the remaining must be filled within 72 hours of initial filling.