ACMA EXAM STUDY MATERIAL WITH
CORRECT SOLUTIONS
UR committee - ANSWER-· 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 - ANSWER-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 - ANSWER-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 - ANSWER-· 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 - ANSWER-·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 - ANSWER-
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 - ANSWER-
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 - ANSWER-committee must review professional
serviced provided, determine med necessity & to promote most efficient use of avail
health facilities/services.
Conditions of Participation (CoP) - ANSWER-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 - ANSWER-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 - ANSWER-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 plan must ID - ANSWER-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 - ANSWER-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.
CORRECT SOLUTIONS
UR committee - ANSWER-· 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 - ANSWER-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 - ANSWER-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 - ANSWER-· 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 - ANSWER-·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 - ANSWER-
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 - ANSWER-
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 - ANSWER-committee must review professional
serviced provided, determine med necessity & to promote most efficient use of avail
health facilities/services.
Conditions of Participation (CoP) - ANSWER-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 - ANSWER-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 - ANSWER-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 plan must ID - ANSWER-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 - ANSWER-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.
