ACMA EXAM STUDY MATERIAL QUESTIONS WITH CORRECT ANSWERS ALREADY PASSED!!

ACMA EXAM STUDY MATERIAL QUESTIONS WITH CORRECT ANSWERS ALREADY PASSED!! UR committee · Consists of >2 practitioners, > 2 must be doctors of medicine/osteopathy. · Must be 1: Institution staff committee; group outside institution; established by local med society & some/all of local hospitals; established manner CMS approved · May not be conducted by person w/direct financial interest in hospital or prof involved in care of pt who's case is under review utilization review Hospitals must have, provides review of services furnished by institution/mbrs of med staff to pts entitled to benefits under M/M programs. scope & freq of UR Plan must provide review for M/M w/respect to med necessity of: · Admissions; duration of stay; professional services provided (including drugs/biologicals) · Review of admissions may be performed before, at or after admission · Reviews may be conducted on sample basis Hospitals paid for IP services under prospective pymt system must conduct review as for · Duration of stays: only reasonably assume to be outlier based on extended LOS & · Professional services: only reasonably assume to be outlier based on extraordinarily high cost Determination regarding admissions/cont stays ·Made by 1 mbr of committee if provider liable for pt care concur w/determination or fail to present views when given chance & must be made by >2 mbrs of committee in all other cases ·Before decision made on admission/cont stay is not med necessary; committee consult providers responsible for pt care, giving change to present views · If committee decides admission/cont stay is not med necessary, written notice to be given w/in 2 d after decision to hospital/pt/providers responsible for care. Extended stay review: hospital not paid under prospective pymt system committee must make periodic review (per UR plan) of ea current IP receiving hospital services in cont of extend duration. Scheduling periodic review may: Be same for all cases, differ for diff class of cases. Extended stay review: hospital paid under prospective pymt system committee must review all cases reasonably assumed to be outlier cases b/c extended LOS exceeds threshold criteria for dx. Hospital not req to review extended stay that does not exceed outlier threshold for dx. Periodic review w/in 7d after day req in UR plan Review of professional services committee must review professional serviced provided, determine med necessity & to promote most efficient use of avail health facilities/services. Conditions of Participation (CoP) hospitals must have effective d/c planning process, focus on pt's goals/tx preferences & include pt/Cg as partners in d/c planning for post-d/c care. Ensure effective transition from hospital to post-d/c care, < factors leading to avoidable readmissions D/c planning process Must ID, early in hospitalization, pts likely to suffer adverse health conseq & d/c in absence of adequate d/c planning & must provide d/c planning eval for pts ID & from req of pt/pt rep/pt physician D/C planning eval must Be made on timely basis to ensure appro arrangements for post-hospital care are made before d/c & avoid unnecessary delays in d/c ·Include: eval of pts likely need for approp post-hospital services (hospice, post-d/c extended care, HH, non-HC, community care providers) & decision of availability of appropriate services of pt's access to those services. · Be included in pt's med record to use in establishing d/c plan & results of eval discussed w/pt · Upon request, hospital must arrange for develop/initial implementation of d/c plan for pt · Be developed by/under supervision of RN/SW or appropriately qualified personnel · Req reg re-eval of condition, ID changes that req revision to d/c plan. Plan updated to reflect · Be assessed by hospital routinely; assess includes: ongoing/periodic review of rep sample of d/c plan; readmissions w/in 30d of prev admission; ensure plan responsive to post-d/c needs · Hospital must assist pt/fam in selecting post-acute care provider by using HHA/SNF/IRF/LTCH data on quality measures/resource use measures. Hospital to ensure post-acute care data is relevant/applicable to pt's goals of care & tx preferences D/C of pt & provision/transmission of pt's needed med info hospital must d/c pt, transfer/refer as needed, w/all necessary med info r/t current course of illness/tx, post-d/c goals, tx prefs, at time of d/c, to appropriate post-acute service/provider/supplier/facility/agencies others responsible for f/u or ancillary care. Requirements r/t post-acute care pt d/c home & referred for HHA or transferred to SNF for post-hospital extended care, or transferred to IRF/LTCH for specialized hospital services Requirements r/t post-acute care req apply Hospital must include in d/c plan, list of HHA/SNF/IRF/ LTCH avail/participating in Medicare program & that serve geographic area (HHA) which pt resides, or for SNF/IRF/LTCH in area requested by pt. HHAs must request to be listed by hospital as avail; list must only be presented to pt for whom HH post-hospital extended care services, SNF/IRF/LTCH services are indicated & appropriate as determined by d/c planning eval. Pt enrolled in managed care orgs, hospital must make pt aware of need to verify w/org which providers/certified suppliers are in network. D/C plan must ID HHA/SNF which pt is referred, in which hospital has disclosable financial interest, & any HHA/SNF that has disclosable financial interest in hospital under Medicare. Hospital must inform pt freedom to choose Medicare providers/suppliers of post-d/c services, respect pt goal of care/tx prefs; not specify/limit qualified provider/supplier avail to pt. Overview of CM Functions CM in hospital/HC systems represent range of services/diverse methods of org structure. Services provided primarily by CM or 2nd by others. Following best reflect concept can be used on ACM exam CM Education CM to ensure/provide ed relevant to effective progress of care, appropriate level of care & safe pt transition. CM Education Specifically Ensure education r/t injury/clinical/disease process is provided by HC team · Provide info to HC team/pt/family/CG regarding avail resources/benefits for acute/post-acute services that ensure pt choice & safe/timely transition · ID clinical/psychosocial/operation learning opportunities that neg affect care or reimbursement & provide HC team/community partners/pt/family/CG education to address/resolve issues CM Care Coordination CM expected to have method for screening/ID/ assessment of pt needing CM; defined standards for ongoing monitoring/interventions that advance progression of care & include: clinical/psychosocial/ financial/operational aspects of care Steps of CM screen/ID, assess, POC, sequence, communication screening/ID screen all pt for clinical/psychosocial/financial/ operational factors that may affect prog of care, using ID criteria stratify pt at risk/barriers/strengths, need CM Assessment CM must have assessment tool that expands knowledge of risks ID in screening process & is complementary to assessment of other clinical disciplines POC review/ensure plan is clinically appropriate, matches pt's care needs, consistent w/pt choice & avail resources Sequencing help ensure consults, testing/procedures are seq in manner approp to pts clinical condition, supports timely/efficient care delivery. To actively intervene/ resolve/ escalate where barriers to service exist Communication verbal/written foundation on which knowledge transfers/collaboration/ relationship building are based; CM liable for documenting info complementary/ contributes to progressions of care CM Compliance CM to be knowledgeable of & ensure compliance with fed/state/local hospital & accreditation req that impact scope of services; CM org structure & staffing/policies/ procedures must meet CMS CoP; All disciplinepractice w/in scope of practice defined by state license regs Transition Mgmt based on team assessment & pt choice/avail resources, CM to integrate key elements & develop/coordinate successful transition plan. Plan begins at CM initial pt encounter & reevaluated/adjusted thru pt's hospital stay Transition Coordination-ID based on assessment, CM ID pts w/post-acute needs include those at risk for readmission, prioritize, & intervene as needed Community Partnership ID avail community resources/potential partners & advocate for resolution of gaps in avail resources/ processes; CM familiarize w/& provide avail info to make informed choice regarding resources/ providers Transition Coordination arrange/ensure all elements of transition plan implemented/communicated to key stakeholders (pt team/family/CG/post-acute providers); convey all needed info for continuity of care, pt safety; verify receipt, provide venue for add questions &/or info requests/needs CM Follow up provide electronic/telephone/f2f contact w/pt/family to validate success of transitional care plan w/in 72 hrs Utilization Mgmt CM expected to advocate for pt while balancing responsibility of stewardship for org & in general the judicial mgmt of resources. CM Med Necessity define method to ensure pt is in appropriate "status" & level of care for clinical condition. Process must include method for 2nd physician review when warranted. Payer Interface CM w/respect to payer req will ensure timely notification/communication of pertinent clinical data to support admission, clinical condition, cont stay & auth of post-acute services. CM will advocate securing reimbursement/resources needed. When no payer auth req exist, CM accepts role as pt/org advocate to manage utilization resources Denials/Appeals CM to proactively prevent med necessity denials by providing education to physicians/staff/pt, interfacing w/payers, & documenting relevant info. CM to provide clinical info necessary for appeals process by cases which med necessity denial has been received. CM to utilize escalation process as needed Avoidable Delays/Days CM to use validated system/defined method for tracking avoidable delays/days & use info to ID/ communicate opportunities for improvement; partake in develop of PI activities relevant to ID opportunities. Overview of CM Expectations accountability, professionalism, collaboration, care coordination, advocacy, resource mgmt Accountability ownership for achievement of optimal outcomes. CM: · Recognize/demonstrate shared accountability, both at individual/team levels; joint responsibility/accountability is inherent in collaborative practice · Follows through on commitments & expects/prompts others to do the same