Healthcare Regulations and 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 and Compliance flashcards as text
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?
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.
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?
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.
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?
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.
Which CMS condition of participation requires hospitals to have a utilization review committee that evaluates the medical necessity of admissions?
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.
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?
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.
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?
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.
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?
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.