CCM - Certified Case Manager Healthcare Regulations and Compliance Questions and Answers 2 — Questions and Answers
Question 1: What is the primary purpose of EMTALA?
- To regulate ambulance response times
- To ensure anyone presenting to an ED receives screening and stabilization regardless of ability to pay (Correct answer)
- To establish ER staffing standards
- To regulate EMT certification
Correct answer: To ensure anyone presenting to an ED receives screening and stabilization regardless of ability to pay
EMTALA requires Medicare-participating hospitals to provide medical screening and stabilization to all regardless of insurance or ability to pay.
Enacted in 1986, EMTALA requires a medical screening examination for anyone who presents and stabilizing treatment before discharge or transfer. Violations result in penalties up to $50,000 per violation and Medicare exclusion.
Question 2: Under the ACA, what does the 'essential health benefits' requirement mandate?
- All Americans must have insurance
- Individual and small group plans must cover ten categories of services (Correct answer)
- Medicare must cover dental and vision
- Employers must provide insurance to all employees
Correct answer: Individual and small group plans must cover ten categories of services
The ACA requires individual and small group plans to cover ten essential health benefit categories.
The ten categories include ambulatory, emergency, hospitalization, maternity, mental health/substance use, prescriptions, rehabilitative, laboratory, preventive, and pediatric services including dental and vision.
Question 3: What is the Stark Law and how does it impact referral practices?
- A law requiring written referrals
- A federal self-referral prohibition preventing physicians from referring Medicare patients to entities where they have financial interest (Correct answer)
- A state nursing practice law
- A facility lighting regulation
Correct answer: A federal self-referral prohibition preventing physicians from referring Medicare patients to entities where they have financial interest
The Stark Law prohibits physician self-referrals to entities where they have financial relationships.
The Stark Law covers designated health services including lab, physical therapy, imaging, and DME. Violations result in payment denial, refunds, civil monetary penalties, and potential False Claims Act liability.
Question 4: What does the Anti-Kickback Statute impose on healthcare referrals?
- It requires kickbacks for referrals
- It prohibits offering or receiving anything of value to induce referrals for federal healthcare program services (Correct answer)
- It applies only to pharma companies
- It regulates medical equipment startup
Correct answer: It prohibits offering or receiving anything of value to induce referrals for federal healthcare program services
The AKS makes it criminal to exchange anything of value to induce referrals for federal healthcare services.
Unlike Stark Law (strict liability, civil, physician-only), AKS applies to anyone, requires intent, and carries criminal penalties including fines up to $100,000 and imprisonment up to 10 years.
Question 5: What is the minimum necessary standard under HIPAA?
- Minimum staff trained on HIPAA
- Limit PHI use and disclosure to the minimum amount necessary for the intended purpose (Correct answer)
- Minimum security measures for electronic records
- Minimum days to respond to record requests
Correct answer: Limit PHI use and disclosure to the minimum amount necessary for the intended purpose
The standard requires limiting PHI access and disclosure to only what is needed for the purpose.
Case managers should access only specific information needed for the task, share only what the receiver needs, and implement role-based access controls. Exceptions include disclosures for treatment and disclosures required by law.
Question 6: What are key provisions of the 21st Century Cures Act relevant to case management?
- Only drug approval
- Promotes health information exchange, bans information blocking, and supports EHR interoperability (Correct answer)
- New licensing requirements
- Case management certification standards
Correct answer: Promotes health information exchange, bans information blocking, and supports EHR interoperability
The Cures Act promotes information exchange, prohibits information blocking, and mandates EHR interoperability.
Key elements include prohibition of information blocking, mandating patient access to electronic health information through standardized APIs, and promoting EHR interoperability. This gives case managers legal backing to request previously difficult-to-obtain information.
CCM - Certified Case Manager Healthcare Regulations and Compliance Questions and Answers 2
What is the primary purpose of EMTALA?