CCM Healthcare Regulations and Compliance 2 — Questions and Answers
Question 1: Under EMTALA, a hospital with an emergency department must provide a medical screening examination to any individual who presents and requests examination. Who is responsible for conducting this screening?
- Any registered nurse on duty
- A qualified medical person as defined by the hospital's bylaws (Correct answer)
- Only an attending physician
- The hospital administrator on call
Correct answer: A qualified medical person as defined by the hospital's bylaws
EMTALA requires a medical screening examination by a qualified medical person, which the hospital defines in its bylaws and may include non-physician practitioners.
Question 2: The Stark Law (Physician Self-Referral Law) prohibits physicians from referring Medicare patients to entities for designated health services if the physician has a financial relationship with that entity. Which of the following is a designated health service under Stark?
- Outpatient psychiatric evaluations
- Physical therapy services (Correct answer)
- Routine office visits
- Preventive screenings only
Correct answer: Physical therapy services
Physical therapy is explicitly listed as a designated health service under the Stark Law, making self-referrals to PT entities with financial relationships prohibited.
Question 3: A case manager discovers that a patient's insurer denied a claim citing lack of medical necessity. Under which federal law does the patient have the right to an internal appeal followed by an external independent review?
- COBRA
- ACA (Affordable Care Act) (Correct answer)
- ERISA only for self-funded plans
- Medicare Part D regulations
Correct answer: ACA (Affordable Care Act)
The ACA established the right to an internal appeal and external independent review for non-grandfathered health plans when claims are denied for lack of medical necessity.
Question 4: Which CMS condition of participation requires hospitals to have a utilization review committee that evaluates the medical necessity of admissions?
- Conditions for Coverage (CfC)
- Conditions of Participation (CoP) – Utilization Review (Correct answer)
- Medicare Advantage regulations
- Joint Commission Accreditation Standards
Correct answer: Conditions of Participation (CoP) – Utilization Review
CMS Conditions of Participation for hospitals include a Utilization Review standard requiring a committee to review admissions and continued stays for medical necessity.
Question 5: A case manager working in a skilled nursing facility must ensure the facility complies with the Minimum Data Set (MDS) requirements. What is the primary regulatory purpose of the MDS?
- To credential nursing staff annually
- To assess residents and drive care planning and reimbursement under Medicare (Correct answer)
- To document OSHA safety inspections
- To report infection control data to the CDC
Correct answer: To assess residents and drive care planning and reimbursement under Medicare
The MDS is a federally mandated comprehensive assessment tool used in SNFs to guide care planning and determine Medicare payment under the Patient-Driven Payment Model.
Question 6: The Anti-Kickback Statute (AKS) prohibits offering or receiving remuneration to induce referrals of federal healthcare program business. Which of the following is a recognized safe harbor under the AKS?
- Paying physicians a percentage of generated revenue
- Space rental arrangements meeting specific fair market value criteria (Correct answer)
- Providing free services to all Medicare beneficiaries
- Waiving copayments for preferred referring physicians
Correct answer: Space rental arrangements meeting specific fair market value criteria
Space rental arrangements that meet the AKS safe harbor criteria—including fair market value rent and a written agreement of at least one year—are protected from prosecution.
Question 7: A case manager notices a pattern where a home health agency consistently receives referrals only from one physician who owns a financial interest in the agency. This arrangement most likely raises concerns under which law?
- HIPAA Privacy Rule
- Stark Law and Anti-Kickback Statute (Correct answer)
- Americans with Disabilities Act
- Fair Labor Standards Act
Correct answer: Stark Law and Anti-Kickback Statute
A physician with a financial interest in a home health agency who refers Medicare patients to it implicates both the Stark Law's self-referral prohibition and the Anti-Kickback Statute.
CCM Healthcare Regulations and Compliance 2
Under EMTALA, a hospital with an emergency department must provide a medical screening examination to any individual who presents and requests examination.
Who is responsible for conducting this screening?