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
A case manager working for a managed care organization must understand the False Claims Act (FCA). Under the FCA, what is the minimum penalty per false claim submitted to a federal healthcare program?
Answer: $13,000–$27,000 per claim (adjusted for inflation)
The FCA imposes civil monetary penalties per false claim (adjusted periodically for inflation, currently in the range of approximately $13,000–$27,000) plus up to three times the government's damages.
The qui tam provision of the False Claims Act allows private individuals to file suit on behalf of the government. What are these individuals called?
Answer: Relators (whistleblowers)
Qui tam relators, commonly called whistleblowers, can file FCA suits on behalf of the government and receive a portion of any recovered funds if the government succeeds.
Under HIPAA's Breach Notification Rule, a covered entity must notify affected individuals of a breach of unsecured PHI within how many days of discovering the breach?
Answer: 60 days
HIPAA's Breach Notification Rule requires covered entities to notify affected individuals within 60 days of discovering a breach of unsecured protected health information.
A case manager is concerned that a colleague shared a patient's diagnosis with the patient's employer without consent. This would violate which HIPAA rule?
Answer: HIPAA Privacy Rule
The HIPAA Privacy Rule governs the use and disclosure of protected health information; disclosing a patient's diagnosis to an employer without authorization or legal basis is a Privacy Rule violation.
A patient enrolled in Medicaid is denied a service by the managed care plan. Under federal Medicaid managed care regulations, the plan must provide notice of the denial and the right to appeal. What is the required timeframe to resolve a standard appeal?
Answer: 30 calendar days
Federal Medicaid managed care regulations require plans to resolve standard internal appeals within 30 calendar days of receiving the appeal.
The Olmstead decision (1999) requires states to provide community-based services to individuals with mental disabilities when appropriate. How does this Supreme Court ruling primarily affect case managers?
Answer: It mandates offering least restrictive community placement when clinically appropriate and the individual agrees
Olmstead requires states to place individuals with disabilities in community settings rather than institutions when treatment professionals determine it is appropriate, the individual does not oppose it, and it can be reasonably accommodated.
Under the ADA and Section 504 of the Rehabilitation Act, healthcare providers receiving federal funding must provide reasonable accommodations to patients with disabilities. Which of the following is an example of a required accommodation?
Answer: Offering qualified sign language interpreters for deaf patients at no charge
Providing qualified sign language interpreters to deaf patients is a required reasonable accommodation under the ADA and Section 504, ensuring effective communication in healthcare settings.