Healthcare Regulations & Compliance Flashcards
7 cards from real CCM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Healthcare Regulations & Compliance flashcards as text
A care manager working in a managed care organization receives a request to deny coverage for a service deemed medically necessary by the treating physician. What regulatory framework governs the appeal process?
Answer: State and federal utilization review and external review laws
State utilization review laws and federal requirements under the ACA mandate specific internal appeal and external independent review processes when coverage for medically necessary services is denied.
The Medicare Conditions of Participation (CoPs) for home health agencies require that a plan of care be reviewed and signed by a physician at least every:
Answer: 60 days
Medicare CoPs require that the home health plan of care be reviewed by the physician and agency at least every 60 days, coinciding with the certification period.
Which federal law prohibits discrimination based on race, color, national origin, disability, age, and sex in health programs receiving federal financial assistance?
Answer: Section 1557 of the Affordable Care Act
Section 1557 of the ACA is the first federal civil rights law prohibiting discrimination based on multiple protected characteristics specifically in health programs and activities receiving federal financial assistance.
What is the primary purpose of a Business Associate Agreement (BAA) under HIPAA?
Answer: To establish the contractual obligation of vendors handling PHI to protect that information
A BAA is a contract between a HIPAA covered entity and a business associate that establishes the permitted uses of PHI and ensures the business associate will safeguard the information.
Under the Omnibus Budget Reconciliation Act (OBRA) 1987, nursing facilities must conduct a comprehensive assessment of each resident using which standardized tool?
Answer: Minimum Data Set (MDS)
OBRA 1987 mandates that nursing facilities use the Minimum Data Set (MDS) as part of the Resident Assessment Instrument to conduct comprehensive assessments for care planning.
The OIG Work Plan is most useful to a care manager compliance officer because it:
Answer: Identifies areas where the OIG intends to focus its audit and enforcement activities
The OIG Work Plan outlines planned audits, evaluations, and inspections so that healthcare organizations can proactively assess their own compliance in those high-risk areas.
Which element is NOT required for a valid informed consent in most US jurisdictions?
Answer: Patient's agreement to waive future liability
Valid informed consent requires disclosure, comprehension, capacity, and voluntary agreement — it cannot include a waiver of the patient's legal rights, which courts generally find unenforceable.