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Case Manager Certification Exam Questions
with Accurate Answers
- Provider
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- Cost correct answer 5 rights of utilization review 211 correct answer federally funded support referral services and crisis management. 25 correct answer the dollar amount the gifts are limited to to avoid conflict of interest 4 parts of clinical pathway correct answer 1. timeline
- categories of care/activities and interventions
- intermediate and long term outcome criteria
- variance tracking are 4 parts of what? 55 correct answer Medicare will begin coverage of home oxygen with an arterial blood gas result at or above a partial pressure of ___mm Hg while at rest on room air.
80% correct answer medicare covers what percent? 80% correct answer Medicare Part B only covers what percent? 88 correct answer medicare will cover home oxygen if O2 sat is at or below _____% while at rest on room air, exercising on room air or while asleep or a greater than normal fall in oxygen level during sleep (a decrease in arterial PO 2 more than 10 mm Hg, or decrease in arterial oxygen saturation more than 5%) associated with symptoms or signs reasonably attributable to hypoxemia (e.g., impairment of cognitive processes and nocturnal restlessness or insomnia). A correct answer What part of Medicare covers skilled nursing facility? abandonment correct answer willful neglect of responsibility of another person by a person who is assigned to care for that patient or by a person in a caregiving position. access, inspect, copy correct answer HIPAA individual right #3 is the individual's right to their health information to do what? accountable care organizations correct answer groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare
all patient refined diagnosis related groups (APDRG) correct answer type of payment with 2 subclasses based on 1. severity of illness (organ system failure or loss of funtion and 2. risk of mortality Americans with disabilities act correct answer this act established in 1990 has 5 titles. companies cannot discriminate and must make reasonable accommodations if they have 15 or more employees, must have access to public transportation, have access to telecommunication devices, and seek restitution for damage caused by inaccessibility of services. Appeal correct answer A formal way of lodging a disagreement with a claim payment or benefit denial arthritis impact measurement scales correct answer health risk assessment: Disease-specific measure of physical, social, and emotional well-being designed as a measure of outcome in arthritis. -scales: mobility, physical activity (walking, bending, lifting), dexterity, household activity (managing money and medications, housekeeping), social activities, activities of daily living, pain, depression, and anxiety. Score range: Range is 0-10 for each section. Total health score 0-60. --> Zero represents good health status, 10 and 60 represent poor health status.
Assess, plan, implement/intervention, monitor/evaluation correct answer 4 stages of case management assult correct answer an intentional tort/act of threatening or attempting to touch without consent. autonomy correct answer respecting the individual's right to make their own decisions Autonomy vs. shame correct answer Erickson 1 1/5- B correct answer What part of Medicare covers durable medical equipment? balanced budget act correct answer act that gives medicare and medicaid services authority to establish and oversee a program that allows private, national accredited organizations to "deem" weather or not a medicare advantage organization is compliant with medicare requirements. example: JCAHO and NCQA Balanced Budget Act correct answer Law enacted in 1977 that created the medicare part C + choice program, also knows as the medicare advantage plan, is a managed care option that allows new types of health plans under private companies to cover medicare benefits at a
capitation correct answer type of payment to a provider for a group of people assigned to them where there is a fixed cost per person, per time period , not dependent on how often that person utilizes the resources. The provider is contracted under a HMO. per member, per month Case management correct answer Ensure patients receive quality cost- effective, safe, high quality, evidence-based care in the least restrictive setting case management correct answer the dynamic and systematic collaborative approach to providing and coordinating health care services to a defined population.
- participative process to identify and facility options and services for meeting individual healthcare needs while decreasing fragmentation and duplication of care and increasing quality and cost effective clinical outcomes. catastrophic and chronic correct answer case management services are needed for patients with what type of injuries or chronic illnesses? change correct answer likilihood of change increases with the patient's belief in the ability to what?
chronic conditions correct answer The affordable care act title 2 section 2703 provided a State option to provide health homes to medicaid enrollees with what? chronic diseases and public health correct answer The affordable care act title 4 increases data collection, analysis, and sharing to improve care coordination and transitions of care for the prevention of what? clinical guidelines correct answer statements to help make decisions about health specific circumstances. clinical pathway correct answer structured multi-disciplined plan of care to support clinical guidelines and protocol to improve continuity and coordination. clinical risk group correct answer adjusting payment based on clinical characteristics and resource demands of a patient. claims based classification system. CMAG correct answer assessment tool. Comprehensive approach to chronic therapy issues, ex: med adherence, COPD, DVR,DM,HTN, CMAG correct answer Case management adherence guidelines
cost sharing correct answer amount of money paid out of pocket, includes copays, deductible. Does not include premiums. Custodial long-term care correct answer Not skilled helps with adl's and medication management. The goal is to maximize Independence. decision tree correct answer used to select the best course of action in decisions where there is no clear decisions. deductible correct answer amount of money that you must pay before the insurance will pay a claim. defamation of character correct answer a quasi intentional tort that includes slander, disclosing information or telling stories about a coworker Denial correct answer Requires: patent and provider notified, clinical rationale, rights to appeal, legally entitled to due process to appeal Dependent edema correct answer Medicare covers home oxygen for patients whose arterial PO 2 is 56-59 mm Hg or saturation is 89%, if there is evidence of____ suggesting congestive Heart Failure.
descriptive screening tool correct answer identifies characteristics about a population to show health prevention. diagnostic related group correct answer pricing formula used by medicare that reimburses a fixed amount based on a diagnosis. Utilization review department case managers evaluate if a diagnostic test is medically necessary. disability insurance correct answer insurance that replaces income lost when the insured person cannot work due to illness or injury based on their own occupation or any occupation. case managers help patients return to work. Discharge planning correct answer Assessing care needs to ensure patients are transitioned safely. disclosures correct answer HIPAA individual right #4 is the right to request an accounting of all health information what? disease management correct answer population specific aggregate data that encourages self care, triage, improved quality and decreased cost. Due process correct answer The right to appeal decisions
evidence based practice correct answer 1. Question
- ID resources
- Critically appraise resources
- Apply evidence
- Reevaluate application of evidence are 5 steps of what? exchanges correct answer The affordable care act title 2 created state health insurance what? This offered choices to individuals and small business. Expedited external review correct answer can be requested if the patient's health status would be jeopardized due to the time frame. also possible if it concerns admission availability of care, continue to stay or a healthcare item but the patient has not been discharged from the facility External review correct answer Handled by an outside Insurance Company when the benefit result is not what was desired. Adverse benefit determination. Needs to be requested Fair hearing correct answer If denied an appeal you have the right to a
fair labor standards act correct answer enforced by the department of labor false imprisonment correct answer an intentional tort or act of using unwarranted restraints family medical leave act (FMLA) correct answer a law that requires employers (50 or more employees) to provide up to 12 weeks of unpaid job-protected leave in a 12 month period for employees who have worked for at least 1 year for a certain family or medical reason.They may also work fewer hours a week or work day if medical condition warrants. This must be granted for births, adoption, foster care, family is sick, to attend to a serious health condition. Doesn't protect your particular job. fee for service correct answer type of payment where providers are paid for each service. felony correct answer an act punishable by death or imprisonment for over one year. (murder, child abuse, patient abuse, neglect) fidelity correct answer followthrough, keeping promises, informed consent. Formal operational: abstract, hypothetical correct answer Piaget's stage 12-adult
the right to participate as fully as possible, be safe, have the least restrictive environment. Health insurance portability and accountability act (HIPAA) correct answer This does not apply in treatment, billing, required reporting, quality assurance, peer review, business planning, training, emergencies health maintenance organization (HMO) correct answer a health insurance provider for a group of people in a geographical area that delivers agreed to set of services and products to an enrolled group for a predetermined periodic payment (usually monthly). Patients have to see in network providers. Your PCP has to give you a referral for outside specialists except: internists, OB/GYN and pediatrics. Requires preauthorization for outside providers. health risk assessment correct answer predictive screening tool: patient's self assessment of their health and how likely they will seek care.
- predicts future health costs
- predicts likely-hood of progression of their illness to a worse condition.
- examples: PHQ-9, etc. heart failure, MI, and pneumonia correct answer the national pilot program on payment bundling under the affordable care act adjusted
payments for hospitals for preventable medicare readmissions for what medical conditions? HEDIS correct answer health care effectiveness data information set HEDIS correct answer tool managed by NCQA used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. 80 measures and 5 domains including: effectiveness, access, experience, UR, descriptive info HIPAA correct answer health care providers are required to: provide security of paper and electronic health records, institute a complaint process to investigate compliance, and train staff on which law? HIPAA Omnibus Rule correct answer final rule mandated by HITEC to increase patient privacy, allows patients to ask for a copy of medical records in electronic form., if a patient pays out of pocket for a service, they can instruct the provider not to share information with the insurance company. histogram correct answer bar graph used to display numerical data. It can show a trend such as a bell shaped. HITEC correct answer increases privacy and security under HIPPA and increases enforcement
IM-CAG correct answer Inter med - complexity assessment grid Industry vs. inferiority correct answer Erickson 5- informed consent correct answer before CM services you must have capacity, voluntariness, and understandable information in order to have what? Initiative vs. guilt correct answer Erickson 3- Integrated case management correct answer 3 functions of ----
- Track patient self management
- Tend/track population management
- Reporting, monitoring quality Integrated CM correct answer Includes well being, disease management, case management, prevention, triage, utilization management Integrity vs. despair correct answer Erickson 65+
intentional tort correct answer an act in which the outcome was planned, although the person may not have expected the outcome to harm anyone. International Organization for Standardization (ISO) correct answer not for profit organizations that identifies and develops standards for everything. InterQual correct answer Clinical decision support tool determines when and how a patient progresses through the continuum.
- organizes resources utilization,
- objective evidence based criteria for assessing appropriate care for patients. Helps fraud/abuae Intimacy vs. isolation correct answer Erickson 18- invasion of privacy correct answer a quasi intentional tort that is a breach of confidentiality Joint Commission correct answer not for profit organization that set performance standards and accredit hospitals, nursing homes, and ambulatory care clinics for safe and effective care with site visits every 3 years. Quality Seal.
