CCM UPDATED EXAM SCRIPT QUESTIONS AND ANSWERS
RATED A+
✔✔Security of health information and electronic signature standards - ✔✔provides a
uniform level of protection of all health information that is housed or transmitted
electronically. pertains to the individual.
✔✔Tax Equity and Fiscal Responsibility ACT of 1982 - ✔✔the purpose of this act is to
control the rising cost of providing health care services to medicare beneficiaries and
has incentives for cost containment. The act:1. established a case based
reimbursement system (DRG) payment system determined the cost of care for selected
diagnoses while also placing limits on rate increases in hospital venues. 2. Exempted
medical rehabilitation from DRGs. Rehabiliation would continue as a cost based
reimbursement system with limits. 3. Amended social security act so that group health
plans pay before medicare for active employees 65-69 years old and for their spouses
in the same age group. 4. revised Age discrimination act by requiring employers to offer
health benefits to active employees 65-69 and their spouses in the same age bracket. 5.
establish peer review organizations to reduce costs associated with the hospital stays of
medicare and medicaid patients. Also established hospice benefit.
✔✔The Mental Health Parity Act of 1996 - ✔✔A statute that forbids health plans from
placing lifetime or annual limits on mental health coverage that are less generous than
those placed on medical or surgical benefits. Excluded substance abuse. If a plan does
cover mental health, it cannot set a separate dollar limit from medical care. Other limits
allowed: limited number of annual outpatient visits; Limited number of annual inpatient
days; a per visit fee; Higher deductibles and copayments without parity in medical and
surgical benefits. If a parity would require an increase of 1% or more in its health care
costs, the plan would be exempt.
✔✔The Pregnancy discrimination act - ✔✔is an amendment to Title VII stating that
employment discrimination based on pregnancy, childbirth, or related medical
conditions is prohibited as a form of sex discrimination
✔✔Newborns and Mother's Health Protection Act of 1996 - ✔✔Health plans may not
restrict benefits for any hospital length of stay in connection with child birth for new born
or her bother to less than 48 hours following a normal vaginal delivery or less than 96
hours following a delivery by cesarean section. They may not require providers to
request for authorization for up to 48/96 hours . May not increase an individuals
coinsurance for any later portion of a 48 hour /96 hour hospital stay. 3. they cannot
provide monetary payments to encourage a mother to accept less than minimum
protections available under NMHPA. They cannot penalizeor other wise reduce or limit
the reimbursement of an attending provider because the provider furnished care to a
mother or newborn in accordance to NMHPA. They cannot provide monetary or other
incentives to an attending provier to induce the provider to furnish care to a mother or
new born in a manner inconsistent with the NMHPA.
,✔✔The Mental Health Parity and Addiction Equity Act of 2008 - ✔✔MHPAEA preserves
the MHPA protections and adds significant new protections, such as extending the
parity requirements to substance use disorders. Although the law requires a general
equivalence in the way MH/SUD and medical/surgical benefits are treated with respect
to annual and lifetime dollar limits, financial requirements and treatment limitations,
MHPAEA does NOT require large group health plans or health insurance issuers to
cover MH/SUD benefits. The law's requirements apply only to large group health plans
and health insurance issuers that choose to include MH/SUD benefits in their benefit
packages. However, the Affordable Care Act builds on MHPAEA and requires coverage
of mental health and substance use disorder services as one of ten EHB categories
✔✔Exceptions to MHPAEA 2008 - ✔✔Except as noted below, MHPAEA requirements
do not apply to:
Non-Federal governmental plans that have 100 or fewer employees; Small private
employers that have 50 or fewer employees; Group health plans and health insurance
issuers that are exempt from MHPAEA based on their increased cost (except as noted
below). Plans and issuers that make changes to comply with MHPAEA and incur an
increased cost of at least 2% in the first year that MHPAEA applies to the plan or
coverage or at least one percent in any subsequent plan year may claim an exemption
from MHPAEA based on their increased cost. If such a cost is incurred, the plan or
coverage is exempt from MHPAEA requirements for the plan or policy year following the
year the cost was incurred. These exemptions last one year. After that, the plan or
coverage is required to comply again; however, if the plan or coverage incurs an
increased cost of at least 1% in that plan or policy year, the plan or coverage could
claim the exemption for the following plan or policy year; Large, self-funded non-Federal
governmental employers that opt-out of the requirements of MHPAEA.
✔✔hard savings - ✔✔Examples of "hard" savings are directly linked to Case
Management. Examples would be reduction in payer denials or decrease in avoidable
days.
✔✔soft savings - ✔✔Examples of "soft" savings are indirectly linked to Case
Management such as lower readmission rates or lower post-op complication rates.
These can be converted into dollars.
✔✔1987 Nursing Home Reform Act - ✔✔The basic objective of the Nursing Home
Reform Act is to ensure that residents of nursing homes receive quality care that will
result in their achieving or maintaining their "highest practicable" physical, mental, and
psychosocial well-being. To secure quality care in nursing homes, the Nursing Home
Reform Act requires the provision of certain services to each resident and establishes a
Residents' Bill of Rights.
✔✔CARF - ✔✔Commission on Accreditation of Rehabilitation Facilities
,✔✔Wickline v. The State of California - ✔✔the point of this litigation is that a
physician/surgeon is still responsible for negligently discharging a patient even if the
financial benefits related to the hospital stay have been exhausted.
Wickline also seems to suggest that a physician can be negligent for not acting more
aggressively as a patient's advocate with third-party payers
✔✔ADA reasonable accommodations - ✔✔-Making existing facilities used by
employees readily accessible to and usable by persons with disabilities.
-Job restructuring, modifying work schedules, reassignment to a vacant position;
-Acquiring or modifying equipment or devices, adjusting or modifying examinations,
training materials, or policies, and providing qualified readers or interpreters.
✔✔The Individuals with Disabilities Education Act (IDEA) - ✔✔Public Law 94-142 - a
law ensuring services to children with disabilities throughout the nation. IDEA governs
how states and public agencies provide early intervention, special education and related
services to more than 6.5 million eligible infants, toddlers, children and youth with
disabilities.
✔✔Abandonment - ✔✔termination of a professional relationship without reasonable
notice to the patient and without an opportunity for the patient to acquire alternative care
or services thereby resulting in injury to the patient.
✔✔Agency - ✔✔relationship between two or more persons by which one consents that
the other (the agent) shall act on his or her behalf. Legal obligations to: 1. use care and
skill 2. act in good faith 3. staying within the limits of authority 4. obeying the principal
and carrying out all reasonable instructions 5. advancing the interests of the principals
6. acting solely on the principal's benefit. Implies a conflict of interest between the case
manager and the employer and the professional duties to the patient.
✔✔Apparent authority - ✔✔(ostensible agency): When a principal has taken such
actions that would indicate to third parties that someone is his or her agent, the principal
is held to have given "apparent authority" to the agent. The principal is held responsible
for the agent's action
✔✔Bad Faith - ✔✔attempt to mislead or decieve another or neglect refusal to fulfill
some duty or some contractual obligation. Implies a conscious of wrong doing.
Example: denying claim to save money.
✔✔Three Components of bad faith claims denials - ✔✔1. absence of a reasonable
basis for denial of benefits.
2. the insurers or agent's knowledge or reckless disregard of the lack of reasonable
basis for denying a claim.
3. misfeasance or maladministration in processing of claims for benefits.
, ✔✔Bill of particulars - ✔✔Amplification of a legal complaint that supplies more
information and detail, thereby giving the defendant a more specific picture of the claims
against him.
✔✔Breach of confidentiality - ✔✔failure of fiduciary duty. Refusal to hold secret a
priviledged communication entrusted by one party to another.
✔✔Claim - ✔✔request for payment from an insurance company. Or a report by the
insured provider of care to the insurance company based on notification from the patient
or the patient's attorney of an event out of which malpractice has been alleged.
✔✔Comparative negligence - ✔✔A method of measuring negiligence among
participants in a suit (defense and plaintiff) in terms of percentages of culpability.
Damages are then diminished in proportion to the amount of negligence attributable to
the complaining party.
✔✔Complaint - ✔✔document by which the plaintiff gives the court and the defendant
notice of the transactions, occurrences, or series of transactions or occurences intended
to be proved and the material elements of each cause of action or defense.
✔✔Corporate negligence - ✔✔legal ground of a managed care liability based on the
corporate activity of the managed care organization itself rather than on the care related
activities of participating healthcare professionals. Examples: Negligent credentialing
and negligent supervision .
✔✔Corporate practice of medicine - ✔✔Legal doctrine that prohibits corporations from
engaging in the practice of medicine. Corporates who recognize this doctrine cannot
employ physicians.
✔✔Damages - ✔✔Monetary compensation awarded for acts of tort for both tangible
(medical expenses, loss wages) and intangible (pain and suffering)
✔✔Discovery - ✔✔Ascertainment of what is not previously known. All evidence that is
material and necessary in the prosecution or defense of action is produced and
exchanged by the parties or as ordered by the court.
✔✔Event (incident) - ✔✔a situation that is reported by the insured provider to his or her
insurance company which may lead to a formal claim or malpractice suit.
✔✔Examination before trial - ✔✔obtaining information by sworn oral testimony
✔✔False Claims Act - ✔✔Federal penalties for those who knowingly present false claim
or against the government. It is illegal to present a false or fraudulent claim upon or
against the US.
RATED A+
✔✔Security of health information and electronic signature standards - ✔✔provides a
uniform level of protection of all health information that is housed or transmitted
electronically. pertains to the individual.
✔✔Tax Equity and Fiscal Responsibility ACT of 1982 - ✔✔the purpose of this act is to
control the rising cost of providing health care services to medicare beneficiaries and
has incentives for cost containment. The act:1. established a case based
reimbursement system (DRG) payment system determined the cost of care for selected
diagnoses while also placing limits on rate increases in hospital venues. 2. Exempted
medical rehabilitation from DRGs. Rehabiliation would continue as a cost based
reimbursement system with limits. 3. Amended social security act so that group health
plans pay before medicare for active employees 65-69 years old and for their spouses
in the same age group. 4. revised Age discrimination act by requiring employers to offer
health benefits to active employees 65-69 and their spouses in the same age bracket. 5.
establish peer review organizations to reduce costs associated with the hospital stays of
medicare and medicaid patients. Also established hospice benefit.
✔✔The Mental Health Parity Act of 1996 - ✔✔A statute that forbids health plans from
placing lifetime or annual limits on mental health coverage that are less generous than
those placed on medical or surgical benefits. Excluded substance abuse. If a plan does
cover mental health, it cannot set a separate dollar limit from medical care. Other limits
allowed: limited number of annual outpatient visits; Limited number of annual inpatient
days; a per visit fee; Higher deductibles and copayments without parity in medical and
surgical benefits. If a parity would require an increase of 1% or more in its health care
costs, the plan would be exempt.
✔✔The Pregnancy discrimination act - ✔✔is an amendment to Title VII stating that
employment discrimination based on pregnancy, childbirth, or related medical
conditions is prohibited as a form of sex discrimination
✔✔Newborns and Mother's Health Protection Act of 1996 - ✔✔Health plans may not
restrict benefits for any hospital length of stay in connection with child birth for new born
or her bother to less than 48 hours following a normal vaginal delivery or less than 96
hours following a delivery by cesarean section. They may not require providers to
request for authorization for up to 48/96 hours . May not increase an individuals
coinsurance for any later portion of a 48 hour /96 hour hospital stay. 3. they cannot
provide monetary payments to encourage a mother to accept less than minimum
protections available under NMHPA. They cannot penalizeor other wise reduce or limit
the reimbursement of an attending provider because the provider furnished care to a
mother or newborn in accordance to NMHPA. They cannot provide monetary or other
incentives to an attending provier to induce the provider to furnish care to a mother or
new born in a manner inconsistent with the NMHPA.
,✔✔The Mental Health Parity and Addiction Equity Act of 2008 - ✔✔MHPAEA preserves
the MHPA protections and adds significant new protections, such as extending the
parity requirements to substance use disorders. Although the law requires a general
equivalence in the way MH/SUD and medical/surgical benefits are treated with respect
to annual and lifetime dollar limits, financial requirements and treatment limitations,
MHPAEA does NOT require large group health plans or health insurance issuers to
cover MH/SUD benefits. The law's requirements apply only to large group health plans
and health insurance issuers that choose to include MH/SUD benefits in their benefit
packages. However, the Affordable Care Act builds on MHPAEA and requires coverage
of mental health and substance use disorder services as one of ten EHB categories
✔✔Exceptions to MHPAEA 2008 - ✔✔Except as noted below, MHPAEA requirements
do not apply to:
Non-Federal governmental plans that have 100 or fewer employees; Small private
employers that have 50 or fewer employees; Group health plans and health insurance
issuers that are exempt from MHPAEA based on their increased cost (except as noted
below). Plans and issuers that make changes to comply with MHPAEA and incur an
increased cost of at least 2% in the first year that MHPAEA applies to the plan or
coverage or at least one percent in any subsequent plan year may claim an exemption
from MHPAEA based on their increased cost. If such a cost is incurred, the plan or
coverage is exempt from MHPAEA requirements for the plan or policy year following the
year the cost was incurred. These exemptions last one year. After that, the plan or
coverage is required to comply again; however, if the plan or coverage incurs an
increased cost of at least 1% in that plan or policy year, the plan or coverage could
claim the exemption for the following plan or policy year; Large, self-funded non-Federal
governmental employers that opt-out of the requirements of MHPAEA.
✔✔hard savings - ✔✔Examples of "hard" savings are directly linked to Case
Management. Examples would be reduction in payer denials or decrease in avoidable
days.
✔✔soft savings - ✔✔Examples of "soft" savings are indirectly linked to Case
Management such as lower readmission rates or lower post-op complication rates.
These can be converted into dollars.
✔✔1987 Nursing Home Reform Act - ✔✔The basic objective of the Nursing Home
Reform Act is to ensure that residents of nursing homes receive quality care that will
result in their achieving or maintaining their "highest practicable" physical, mental, and
psychosocial well-being. To secure quality care in nursing homes, the Nursing Home
Reform Act requires the provision of certain services to each resident and establishes a
Residents' Bill of Rights.
✔✔CARF - ✔✔Commission on Accreditation of Rehabilitation Facilities
,✔✔Wickline v. The State of California - ✔✔the point of this litigation is that a
physician/surgeon is still responsible for negligently discharging a patient even if the
financial benefits related to the hospital stay have been exhausted.
Wickline also seems to suggest that a physician can be negligent for not acting more
aggressively as a patient's advocate with third-party payers
✔✔ADA reasonable accommodations - ✔✔-Making existing facilities used by
employees readily accessible to and usable by persons with disabilities.
-Job restructuring, modifying work schedules, reassignment to a vacant position;
-Acquiring or modifying equipment or devices, adjusting or modifying examinations,
training materials, or policies, and providing qualified readers or interpreters.
✔✔The Individuals with Disabilities Education Act (IDEA) - ✔✔Public Law 94-142 - a
law ensuring services to children with disabilities throughout the nation. IDEA governs
how states and public agencies provide early intervention, special education and related
services to more than 6.5 million eligible infants, toddlers, children and youth with
disabilities.
✔✔Abandonment - ✔✔termination of a professional relationship without reasonable
notice to the patient and without an opportunity for the patient to acquire alternative care
or services thereby resulting in injury to the patient.
✔✔Agency - ✔✔relationship between two or more persons by which one consents that
the other (the agent) shall act on his or her behalf. Legal obligations to: 1. use care and
skill 2. act in good faith 3. staying within the limits of authority 4. obeying the principal
and carrying out all reasonable instructions 5. advancing the interests of the principals
6. acting solely on the principal's benefit. Implies a conflict of interest between the case
manager and the employer and the professional duties to the patient.
✔✔Apparent authority - ✔✔(ostensible agency): When a principal has taken such
actions that would indicate to third parties that someone is his or her agent, the principal
is held to have given "apparent authority" to the agent. The principal is held responsible
for the agent's action
✔✔Bad Faith - ✔✔attempt to mislead or decieve another or neglect refusal to fulfill
some duty or some contractual obligation. Implies a conscious of wrong doing.
Example: denying claim to save money.
✔✔Three Components of bad faith claims denials - ✔✔1. absence of a reasonable
basis for denial of benefits.
2. the insurers or agent's knowledge or reckless disregard of the lack of reasonable
basis for denying a claim.
3. misfeasance or maladministration in processing of claims for benefits.
, ✔✔Bill of particulars - ✔✔Amplification of a legal complaint that supplies more
information and detail, thereby giving the defendant a more specific picture of the claims
against him.
✔✔Breach of confidentiality - ✔✔failure of fiduciary duty. Refusal to hold secret a
priviledged communication entrusted by one party to another.
✔✔Claim - ✔✔request for payment from an insurance company. Or a report by the
insured provider of care to the insurance company based on notification from the patient
or the patient's attorney of an event out of which malpractice has been alleged.
✔✔Comparative negligence - ✔✔A method of measuring negiligence among
participants in a suit (defense and plaintiff) in terms of percentages of culpability.
Damages are then diminished in proportion to the amount of negligence attributable to
the complaining party.
✔✔Complaint - ✔✔document by which the plaintiff gives the court and the defendant
notice of the transactions, occurrences, or series of transactions or occurences intended
to be proved and the material elements of each cause of action or defense.
✔✔Corporate negligence - ✔✔legal ground of a managed care liability based on the
corporate activity of the managed care organization itself rather than on the care related
activities of participating healthcare professionals. Examples: Negligent credentialing
and negligent supervision .
✔✔Corporate practice of medicine - ✔✔Legal doctrine that prohibits corporations from
engaging in the practice of medicine. Corporates who recognize this doctrine cannot
employ physicians.
✔✔Damages - ✔✔Monetary compensation awarded for acts of tort for both tangible
(medical expenses, loss wages) and intangible (pain and suffering)
✔✔Discovery - ✔✔Ascertainment of what is not previously known. All evidence that is
material and necessary in the prosecution or defense of action is produced and
exchanged by the parties or as ordered by the court.
✔✔Event (incident) - ✔✔a situation that is reported by the insured provider to his or her
insurance company which may lead to a formal claim or malpractice suit.
✔✔Examination before trial - ✔✔obtaining information by sworn oral testimony
✔✔False Claims Act - ✔✔Federal penalties for those who knowingly present false claim
or against the government. It is illegal to present a false or fraudulent claim upon or
against the US.
