CCM - Certified Case Manager Healthcare Regulations and Compliance Questions and Answers — Questions and Answers
Question 1: A case manager is completing an admission assessment for a 78-year-old client being admitted to a skilled nursing facility. To comply with the Patient Self-Determination Act (PSDA), which of the following actions is required?
- Ensuring the client's medical power of attorney is a family member.
- Providing the client with a standardized advance directive form to complete immediately.
- Informing the client of their right to accept or refuse medical treatment and asking if they have an advance directive. (Correct answer)
- Requiring the client to formulate an advance directive before care can be provided.
Correct answer: Informing the client of their right to accept or refuse medical treatment and asking if they have an advance directive.
The Patient Self-Determination Act (PSDA) of 1990 requires healthcare institutions like hospitals and skilled nursing facilities that receive Medicare/Medicaid funding to inform patients of their rights under state law to make decisions concerning their medical care. This includes the right to accept or refuse treatment and the right to formulate advance directives. The facility must also ask if the patient has an advance directive and document this in the medical record.
Question 2: A hospital case manager is participating in a multidisciplinary rounds meeting in a busy, open-style nursing station. The team begins discussing a well-known local celebrity's complex diagnosis and challenging social situation. This action constitutes a potential violation of which federal regulation?
- Emergency Medical Treatment and Labor Act (EMTALA)
- Health Insurance Portability and Accountability Act (HIPAA) (Correct answer)
- The Stark Law
- The Affordable Care Act (ACA)
Correct answer: Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule protects all individually identifiable health information. Discussing a patient's protected health information (PHI) in a public or semi-public area where the conversation can be overheard by those not involved in the patient's care is a common HIPAA violation. Care coordination discussions should occur in a private setting to protect patient confidentiality.
Question 3: A person presents to a hospital emergency department with acute abdominal pain but has no identification or insurance information. According to the Emergency Medical Treatment and Labor Act (EMTALA), what is the hospital's primary obligation?
- Arrange an immediate transfer to the nearest public hospital.
- Provide a medical screening examination to determine if an emergency medical condition exists. (Correct answer)
- Obtain authorization from a hospital administrator before providing treatment.
- Contact local law enforcement to help identify the individual before initiating care.
Correct answer: Provide a medical screening examination to determine if an emergency medical condition exists.
EMTALA, also known as the "anti-dumping" law, requires Medicare-participating hospitals with emergency departments to provide a medical screening examination (MSE) to any individual who comes to the emergency department seeking treatment, regardless of their ability to pay or insurance status. If an emergency medical condition is found, the hospital must provide stabilizing treatment or an appropriate transfer if they lack the capability to stabilize the patient.
Question 4: A hospital-employed physician refers a Medicare patient for home health services to an agency in which the physician has a direct financial ownership interest. This arrangement is most likely to be scrutinized under which federal law?
- The Patient Safety and Quality Improvement Act (PSQIA)
- The Health Information Technology for Economic and Clinical Health (HITECH) Act
- The Physician Self-Referral Law (Stark Law) (Correct answer)
- The False Claims Act (FCA)
Correct answer: The Physician Self-Referral Law (Stark Law)
The Physician Self-Referral Law, commonly known as the Stark Law, prohibits physicians from referring Medicare or Medicaid patients for certain designated health services (DHS), such as home health, to an entity with which the physician or an immediate family member has a financial relationship, unless a specific exception applies. The law is intended to prevent financial incentives from influencing a physician's medical judgment.
Question 5: A case manager is working with a client being treated at a federally-assisted substance use disorder (SUD) program. The client's employer calls the case manager directly, requesting confirmation of the client's treatment dates for an FMLA claim. According to 42 CFR Part 2, what is the case manager's most appropriate action?
- Provide the dates, as FMLA is a legally protected reason for disclosure.
- Inform the employer that the information can only be released with the client's specific written consent that meets Part 2 requirements. (Correct answer)
- Refuse to provide the information under any circumstances to protect the client.
- Tell the employer to obtain a standard court subpoena for the records.
Correct answer: Inform the employer that the information can only be released with the client's specific written consent that meets Part 2 requirements.
42 CFR Part 2 provides stringent federal protections for the confidentiality of records related to substance use disorder treatment from federally assisted programs. Disclosure of any identifying information, including confirmation of patient status, requires specific written patient consent that is more rigorous than a standard HIPAA release. A general release, verbal permission, or even a standard subpoena is insufficient under these regulations.
Question 6: Which program, established by the Affordable Care Act (ACA), directly penalizes hospitals by reducing Medicare payments for higher-than-expected rates of 30-day readmissions for specific conditions like heart failure and pneumonia?
- Accountable Care Organization (ACO) Program
- Hospital Value-Based Purchasing (VBP) Program
- Bundled Payments for Care Improvement (BPCI) Initiative
- Hospital Readmissions Reduction Program (HRRP) (Correct answer)
Correct answer: Hospital Readmissions Reduction Program (HRRP)
The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program established under the ACA that reduces payments to hospitals with excess 30-day readmissions for targeted clinical conditions. The program's goal is to incentivize hospitals to improve care coordination, discharge planning, and post-discharge follow-up to prevent unnecessary readmissions.
CCM - Certified Case Manager Healthcare Regulations and Compliance Questions and Answers
A case manager is completing an admission assessment for a 78-year-old client being admitted to a skilled nursing facility.
To comply with the Patient Self-Determination Act (PSDA), which of the following actions is required?