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NEW QUESTION # 97
Which of the following should a risk manager consider when evaluating the effectiveness of a claims management program?
* indemnity-to-expense ratios
* total number of cases reported
* percentage of cases resolved within reserves
* percentage of cases identified prior to claim
Answer: B
Explanation:
According to Health Care Risk Management principles outlined by ASHRM and the American Hospital Association Certification Center, evaluation of a claims management program focuses on efficiency, financial accuracy, and proactive identification of risk exposures.
Indemnity-to-expense ratios are important performance indicators that measure the proportion of funds spent on compensation versus defense costs. A balanced ratio reflects efficient claim handling and appropriate litigation management. The percentage of cases resolved within reserves evaluates the accuracy of initial reserve setting and ongoing claims assessment, demonstrating financial forecasting effectiveness.
Additionally, the percentage of cases identified prior to formal claim filing reflects proactive risk identification and early intervention practices, which may reduce litigation costs and improve resolution outcomes.
In contrast, the total number of cases reported alone does not measure program effectiveness, as volume may be influenced by patient population, service lines, or reporting culture rather than management quality.
Claims and litigation objectives emphasize accurate reserving, early case identification, and cost-effective resolution strategies. Therefore, indemnity-to-expense ratios, resolution within reserves, and early case identification are appropriate metrics for evaluating the effectiveness of a claims management program.
NEW QUESTION # 98
A doctor fails to administer an indicated test, and the patient deteriorates and must be admitted. This is an example of:
Answer: A
Explanation:
Failing to order or perform an indicated test can represent a diagnostic process failure-an omission that delays recognition of deterioration, leading to harm and escalation of care. Risk management objectives treat diagnostic safety as a systems issue: access to decision support, timely follow-up of abnormal results, clear responsibility for test ordering and review, effective handoffs, and adequate staffing/workload conditions to avoid missed steps. Such errors are often linked to underuse in the IOM quality framework (failure to provide beneficial service) and can drive claims due to preventable worsening. Preventive strategies include standardized pathways, trigger tools for abnormal labs, closed-loop test result management, and teamwork practices that encourage escalation when clinical concern persists despite uncertainty.
NEW QUESTION # 99
The Patient Safety and Quality Improvement Act of 2005 includes provisions to
* amend the Public Health Service Act to establish procedures for the voluntary confidential reporting of medical errors.
* enable the creation of patient safety organizations PSOs.
* require mandatory reporting to PSOs.
* classify patient safety work product reported to PSOs as privileged and confidential.
Answer: B
Explanation:
According to Health Care Risk Management standards established by ASHRM and the American Hospital Association Certification Center, the Patient Safety and Quality Improvement Act of 2005 amended the Public Health Service Act to promote voluntary reporting of patient safety events. The Act established a federal framework to encourage confidential reporting and analysis of medical errors in order to improve patient safety.
The law enabled the creation and certification of Patient Safety Organizations PSOs, which collect and analyze patient safety data submitted by healthcare providers. Importantly, the Act designates patient safety work product submitted to PSOs as privileged and confidential, providing federal legal protections against disclosure in most civil, criminal, or administrative proceedings. This privilege encourages candid reporting and system-wide learning.
However, reporting to PSOs is voluntary, not mandatory. The Act was specifically designed to foster participation by offering confidentiality protections rather than imposing compulsory reporting requirements.
Legal and regulatory objectives in healthcare risk management emphasize understanding the scope of federal protections and ensuring proper designation and handling of patient safety work product. Therefore, provisions 1, 2, and 4 are correct, while mandatory reporting to PSOs is not required under the Act.
NEW QUESTION # 100
What is the voluntary relinquishment by the insurer or self-insurer of the right to recover from a third party?
Answer: B
Explanation:
Subrogation is the insurer's right to seek recovery from a responsible third party after paying a loss. Awaiver of subrogationclause means the insurer (or self-insured entity) gives up that recovery right, usually to support business relationships and reduce litigation between contracting parties. Risk financing objectives include understanding when waivers are acceptable (balanced against increased retained loss), ensuring the waiver aligns with insurance policy endorsements, and preventing unintended coverage gaps. Poorly managed waivers can shift costs back onto the organization and complicate recovery efforts. Contracts should be reviewed to ensure the waiver is mutual when appropriate and consistent with the organization's risk appetite and insurance program.
NEW QUESTION # 101
An intervention between parties to promote reconciliation, settlement, or compromise is
Answer: A
Explanation:
According to Health Care Risk Management standards supported by ASHRM and the American Hospital Association Certification Center, mediation is a form of alternative dispute resolution designed to facilitate voluntary settlement between parties. In mediation, a neutral third party assists disputing parties in communicating, clarifying issues, and exploring mutually acceptable resolutions. The mediator does not impose a binding decision but guides negotiation toward compromise and reconciliation.
Arbitration differs in that the neutral arbitrator typically renders a decision that may be binding, depending on the agreement between parties. Jury trials and bench trials involve formal court proceedings where a judge or jury determines liability and damages based on legal standards and evidence. These processes are adversarial and result in judicial determinations rather than negotiated compromise.
Claims and litigation objectives emphasize cost containment, early resolution, and reduction of adversarial conflict when appropriate. Mediation can reduce defense expenses, shorten case duration, and preserve professional relationships. It also provides greater confidentiality and flexibility than courtroom litigation.
Therefore, the intervention specifically intended to promote reconciliation, settlement, or compromise between parties is mediation.
NEW QUESTION # 102
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