Managed Care Activities (Verb) include which items?

• A. Utilization management, prior authorization, network design, payment policies
• B. Medical research and development, pharmacovigilance
• C. Hospital construction and project management
• D. Public health surveillance and reporting

Answer: (A)

Managed care activities focus on guiding care and controlling costs while maintaining quality. Utilization management is about reviewing medical services to ensure they are appropriate and necessary, helping prevent unnecessary tests or procedures. Prior authorization is a specific tool within utilization management that requires approval from the plan before providing certain services or medications, ensuring they meet coverage criteria. Network design involves selecting and organizing the providers and facilities that form the plan’s exclusive network, which helps coordinate care and negotiate favorable terms. Payment policies determine how providers are reimbursed and can align incentives with cost containment and quality.

The other areas fall outside typical managed care operations: medical research and development and pharmacovigilance relate to drug safety and product development; hospital construction and project management deal with capital projects; and public health surveillance and reporting pertains to population health monitoring and reporting.