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
Under Medicaid managed care regulations, states must ensure that managed care organizations meet minimum medical loss ratio (MLR) standards. What percentage of premium revenue must be spent on clinical services and quality improvement?
Answer: 85%
Federal Medicaid managed care regulations require that Medicaid MCOs meet an 85% MLR, meaning at least 85% of premium revenue must be spent on clinical services and quality improvement activities.
Which law protects employees from retaliation when they in good faith report suspected healthcare fraud or compliance violations?
Answer: The False Claims Act's anti-retaliation provision
The False Claims Act contains a strong anti-retaliation provision that protects employees from being discharged, demoted, or harassed for reporting or participating in investigations of fraud against the government.
A skilled nursing facility care manager is assessing whether a patient meets Medicare Part A criteria. Which of the following is a qualifying requirement for Medicare SNF coverage?
Answer: A 3-day prior qualifying inpatient hospital stay
Medicare Part A SNF coverage requires a qualifying inpatient hospital stay of at least 3 consecutive days (not counting the discharge day) within 30 days before the SNF admission.
The Conditions of Participation for hospitals require a utilization review (UR) committee to evaluate the medical necessity of admissions. Who must be excluded from voting on individual cases within this committee?
Answer: The attending physician responsible for the patient's care
CMS Conditions of Participation require that the attending physician responsible for a patient's case is excluded from voting on the utilization review of that case to avoid conflicts of interest.
Under the Affordable Care Act, which provision requires most health insurance plans to cover preventive services without cost-sharing?
Answer: Section 2713 — Coverage of Preventive Health Services
ACA Section 2713 requires non-grandfathered health plans to provide coverage for evidence-based preventive services rated A or B by the USPSTF without imposing cost-sharing requirements.
A care manager receives a subpoena for a patient's records in a civil lawsuit. What is the appropriate first step?
Answer: Notify the patient and the organization's legal counsel before releasing any records
Upon receiving a subpoena, the appropriate first step is to notify the patient and consult legal counsel, as a subpoena alone (without a court order) may not override HIPAA without specific procedural safeguards.
Which of the following best describes the purpose of a Corporate Integrity Agreement (CIA) in healthcare compliance?
Answer: A settlement agreement with the OIG requiring specific compliance measures as an alternative to program exclusion
A CIA is a formal agreement between the OIG and a healthcare organization that has engaged in fraud, allowing the organization to remain in federal programs in exchange for implementing rigorous compliance measures and monitoring.