CCM Exam Study Guide – HPM 327 Questions with Verified Answers,100% CORRECT, Exams of Nursing

Download CCM Exam Study Guide – HPM 327 Questions with Verified Answers,100% CORRECT and more Exams Nursing in PDF only on Docsity! CCM Exam Study August 2017-Abi's 91 Questions with Verified Answers The most effective cost containment strategy used in pharmacy benefits management is: A) Volume purchase discounts. B) Use of mail order pharmacies. C) Use of a preferred drug list. D) Use of generic drugs. - CORRECT ANSWER Answer: D) Use of generic drugs. Rationale: While all of these strategies are used to contain costs in pharmacy benefits management, the most cost effective strategy is to use generic medications in lieu of name brand drugs. Case management facilitates the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. The case manager's primary function is: A) Care coordination B) Cost containment C) Outcomes management D) Education - CORRECT ANSWER Answer: A) Care coordination The case manager links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client- centered, timely, efficient, and equitable. This approach achieves optimum value and desirable outcomes for all—the clients, their support systems, the providers, and the payers. All four are case management functions, but the primary function the case manager is coordination of care. Case managers facilitate client autonomy and wellness through: A) Persuasion, financial incentives, and communication. B) Assessing, goal setting, and service facilitation. C) Caregiver education and resource management. D) Advocacy, communication, and education. - CORRECT ANSWER Answer D) Advocacy, communication, and education. http://ccmcertification.org/.../definition-and-philosophy-cas... Case management facilitates the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, 4 education, resource management, and service facilitation. Which organization assists with the employment and retention employees with disabilities by providing information on job accommodations? A) Americans with Disabilities Act (ADA) B) Job Accommodation Network (JAN) C) U. S. Department of Labor D) American Civil Liberties Union (ACLU) - CORRECT ANSWER Answer: B) Job Accommodation Network (JAN) Resource: http://askjan.org/blog/?page_id=2 Rationale: The Job Accommodation Network is a service provided by the U.S. Department of Labor's Office of Disability Employment Policy (ODEP). JAN's mission is to facilitate the employment and retention of workers with disabilities by providing information on job accommodations. JAN represents the most comprehensive resource for job accommodations available. A health coach is working with a client on weight loss. What is the most important thing the healthcoach should do when setting goals? A) Set small, achievable goals for the client. B) Set long term goals for the client to have a normal BMI. C) Not make the client aware of the goal, so that they do not feel pressured. D) Assist the client to set goals that are meaningful to the client based on information obtained during the motivational interview - CORRECT ANSWER Answer: D) Assist the client to set goals that are meaningful to the client based on information obtained during the motivational interview. Resource: Rationale: During the motivational interview, the health coach helps the client discover issues that are most concerning to the client and discovers the inner motivations to make necessary changes. This information can then be used to make goals that are meaningful to the client, increasing the likelihood of successfully achieving the goals. The health coach should not make goals for the client but should assist the client in setting goals. D) Bipolar disorder - CORRECT ANSWER Answer: B) Kleptomania Rationale: The Americans with Disabilities Act prohibits workplace discrimination against individuals with, or with a history of, psychiatric disabilities not controlled by medication. It does not however, protect criminal diagnoses, such as pyromania or kleptomania. Which one of the following is used to evaluate an injured worker and assist in determining job placement, job accommodation, or return to work after injury or illness? A) Functional capacity evaluation (FCE) B) Functional independence measures (FIM) C) Instrumental activities of daily living (IADL) D) Job analysis - CORRECT ANSWER Answer: A) Functional capacity evaluation (FCE) Resource: CCMC Glossary of terms Rationale: Functional Capacity Evaluation (FCE): A systematic process of assessing an individual's physical capacities and functional abilities. The FCE matches human performance levels to the demands of a specific job or work activity or occupation. It establishes the physical level of work an individual can perform. The FCE is useful in determining job placement, job accommodation, or return to work after injury or illness. FCEs can provide objective information regarding functional workability in the determination of occupational disability status. The Americans with Disabilities Act protects individuals with drug addiction in which of the following employment situations? A) The individual is applying for employment and has active drug use. B) The individual is employed, found positive for drug use but has agreed to start a rehabilitation program. C) An applicant who is not qualified for the position but successfully completed a drug rehabilitation program. D) An employee with a recently found history of drug use, who has been successfully rehabbed and is no longer using drugs. - CORRECT ANSWER Answer: D) An employee with a recently found history of drug use, who has been successfully rehabbed and is no longer using drugs. Resource: Rationale: The Americas with Disabilities Act provides protection for qualified applicants and employees with drug addiction if they have been successfully rehabilitated and no longer use drugs or alcohol. It does not protect employees who are currently using drugs or alcohol. Mr. Jenkins has advanced Alzheimers and requires 24 care. Which of the following may help cover his cost at an Alzheimer's care facility? A) Long Term Disability Insurance B) Long Term Care Insurance C) His medical benefit D) Unemployment Compensation - CORRECT ANSWER Answer: B) Long Term Care Insurance Resource: Rationale: A long-term care policy may offset some or all of the cost of long-term care. These policies vary widely, but usually, have a limit on the dollar amount or number of years one can receive the benefit. A woman is hospitalized for a c-section. She is covered by her own employer health plan and as a dependent by her husband's employer health plan. According to COB, which health plan pays first? A) Family Medical Leave Act (FMLA) B) Her short term disability policy C) Her employee health plan D) Her husband's employee health plan - CORRECT ANSWER Answer: C) Her employee health plan Resource: Rationale: Under COB rules, the insurance plan covering the individual as an employee is the primary payer. When dealing with a maladaptive family, the case manager should: A) Encourage them to have a single caregiver provide all assistance to the patient so that here is consistency. B) Refer them to support groups or family counseling. C) Close the member to case management as there will be no benefit from the service. D) Arrange for placement of the patient into an appropriate facility. - CORRECT ANSWER Answer: B) Refer them to support groups or family counseling. Resource: Rationale: The case manager can make a referral to family counseling or support groups. She can also encourage the family to maintain as much of their normal routine as possible. Ms. Waters is 65 years old and recently diagnosed with liver cancer. She tells you she has only worked "under the table" as a babysitter for family and friends. She has never been formally employed. Which of the following is she most likely to receive. A) Medicare B) Unemployment C) Medicaid D) Social Security Disability Insurance (SSDI) - CORRECT ANSWER Answer: C) Medicaid Resource: Rationale: Medicare, SSDI, and unemployment are all insurances funded by employees wages. As Ms. Waters has never paid into these, she would not be eligible to receive these benefits. Medicaid is based on need, not work history. Of the choices, Ms. Waters is most likely to receive Medicaid. Which of the following is not Durable Medical Equipment? A) Wheelchair B) CPAP C) Enteral feeding pump D) Wound care supplies - CORRECT ANSWER Resource: CCMC Glossary of terms; https://secure.ssa.gov/poms.nsf/lnx/0600610200 Rationale: Durable Medical Equipment (DME): Equipment needed by patients for self-care. Usually, it must withstand repeated use, is used for a medical purpose, and is appropriate for use in the home setting. Medicare provides health insurance benefits to all of the following except: A) A 65-year-old receiving Social Security Benefit B) A 25-year-old receiving Social Security Disability for 5 months C) A 52-year-old diagnosed with Lou Gehrig's Disease 3 months ago D) A 12-year-old diagnosed with End Stage Renal Disease (ESRD) requiring dialysis - CORRECT ANSWER Answer: B) A 25-year-old receiving Social Security Disability for 5 months Resource: A 68-year-old continues to work full time at a small company with 9 employees. He also received Medicare. When he developed pneumonia and is hospitalized, which plan pays primary? A) His employer health plan B) Medicare C) Medicare and the employer health plan split the claim 50/50 D) Workers' compensation - CORRECT ANSWER Answer: B) Medicare Resource: Rationale: • Medicare is primary if age 65 or older and retired. • Medicare is primary when 65 or older and covered under employer plan with less than 20 employees. • Medicare is primary when age 65 or older and coved on spouses plan, when spouse is working for an employer with less than 20 employees. • Employer plan is primary when age 65 or older and covered due to working for an employer with 20 or more employees. • Employer plan is primary when age 65 or older and covered on spouses plan when the spouse is working for an employer with 20 or more employees. Which system reimburses for home care services based on the OASIS assessment under Medicare? A) Diagnostic Related Group (DRG) B) Home Health Resource Group (HHRG) C) Case Mix Group (CMG) D) Ambulatory Payment Classification System (APC) - CORRECT ANSWER Answer: B) Home Health Resource Group (HHRG) Resource: CCMC Glossary of Terms Rationale: Home Health Resource Group (HHRG): Groupings for prospective reimbursement under Medicare for home health agencies. Placement into an HHRG is based on the OASIS score. Reimbursement rates correspond to the level of home health provided. Which criteria must be met to be eligible for hospice? A) A signed DNR. B) A physician certifies that the patient has a life expectancy of 6 months or less. C) Intractable pain. D) The need for palliative care. - CORRECT ANSWER Answer: B) A physician certifies that the patient has a life expectancy of6 months or less. Resource: Rationale: The primary criteria for hospice is certification from a physician of a life expectancy of 6 months or less. Although a signed DNR is preferred it is not required in all hospice programs to initiate hospice care. Treatment for intractable pain and palliative care can be provided by a hospice program, but can also be provided by other healthcare providers in the absence of a terminal diagnosis. Which type of utilization management occurs prior to hospitalization to determine if the requested services are medically necessary? A) Concurrent Review B) Prospective Review C) Retrospective Review D) Case Management Referral - CORRECT ANSWER Answer: B) Prospective Review Resource: CCMC Glossary of Terms Rationale: Prospective Review: A method of reviewing possible hospitalization before admission to determine necessity, and estimated length of stay. Retrospective Review: A form of medical records review that is conducted after the patient's discharge to track appropriateness of care and consumption of resources. Which statement by a client would make the case manager question the clients Health Literacy? A) "I prefer to learn new health information by hearing it." B) "I don't remember what my doctor said. Ask my daughter, she handles that for me." C) "I have to keep a list of all my medications and doctors so I can remember them all." D) "Can you write that down for me?" - CORRECT ANSWER Answer: B) "I don't remember what my doctor said. Ask my daughter, she handles that for me." Resource: Rationale: Signs that a patient may have low health literacy include making statements that another person handles their medications, or deferring questions about their health to a family member. Which system reimburses for Skilled Nursing Facility care based on the MDS assessment tool under Medicare? A) Diagnostic Related Group (DRG) B) Resource Utilization Group (RUG) C) Case Mix Group (CMG) D) Per diem - CORRECT ANSWER Answer: B) Resource Utilization Group (RUG) Resource: CCMC Glossary of Terms Rationale: Resource Utilization Group (RUG): Classifies skilled nursing facility patients into 7 major hierarchies and 44 groups. Based on the MDS, the patient is classified into the most appropriate group, and with the highest reimbursement. The best interpreter to interpret for a transplant client who's primary language is German and speaks "a little English" is: A) The client's spouse B) A friend of the client C) A professional interpreter D) No interpreter is necessary as the client speaks some English and reading material in German can be provided. - CORRECT ANSWER Answer: C) A professional interpreter Resource: Rationale: Although friends and family may be a convenient source of interpretation, they should not be the primary interpreter. The client may not feel comfortable disclosing some information to family members or friends regarding their private health matters. The ability of the client to speak "a little" English does not ensure he is properly understanding the information provided. Sue is a 25-year-old client with aggressive breast cancer. During your initial assessment, she identified as being a devout Catholic. During your last interactions, she stated she, "does not know why God is punishing her like this. She has always been a good Catholic." Which of the following would be the best to refer Sue to? A) A support group for breast cancer patients B) A counselor C) A psychiatrist D) A priest - CORRECT ANSWER Rationale: Although Sue may benefit from any of these services, her primary struggle is spiritual. Because of her devout faith, a priest would be the most appropriate initial referral. C) 49-year-old male with 6 ER visits and 2 inpatient hospitalizations in the last 2 months D) 25-year-old female post motor vehicle accident who sustained pelvic and bilateral lower extremity fractures and has no family or support system - CORRECT ANSWER Answer: B) 88-year-old male who resides in a skilled nursing facility and developed a urinary tract infection http://www.cmsa.org/.../pdf/memberonly/StandardsOfPractice.pdf Examples of high-risk screening criteria include, but are not limited to: • Age • Poor pain control • Low functional status or cognitive deficits • Previous home health and durable medical equipment usage • History of mental illness or substance abuse, suicide risk, or crisis intervention • Chronic, catastrophic, or terminal illness • Social issues such as a history of abuse, neglect, no known social support, or lives alone • Repeated emergency department visits • Repeated admissions • Need for admission or transition to a post-acute facility • Poor nutritional status • Financial issues Mr. Williams is a 72-year-old male client with a low-income. He has been losing weight since his wife's death 6 months ago. He states he does not like to cook and has been living off of junk food since her death. The best resource for Mr. Williams is: - CORRECT ANSWER Answer: A) A meal delivery service. Resource: Rationale: Home delivery services, such as Meals on Wheels, provide reasonably priced meals delivered to the home. A housekeeper/cook and cooking classes are usually out of the budget for most low-income people. An assisted living facility is usually not covered by Medicare or insurance and can be expensive. Mary is a 37-year-old mother of two who is paralyzed from the waist down after a motor vehicle accident. She tells her case manager, "I can never be a good mom from this wheelchair." The case manager should: A) Ignore the comment. B) Encourage the patient to explore her feelings regarding this. C) Tell the client she is lucky to be alive and should be thankful. D) Report her to social services. - CORRECT ANSWER Answer: B) Encourage the patient to explore her feelings regarding this. Resource: Rationale: The case manager should encourage the patient to her feelings without judgment, in a supportive environment. The first thing for the case manager to do when a client is not compliant with the plan of care is to: A) Close the member to case management. B) Discuss barriers to compliance with the member. C) Notify the client's physician. D) Request a mental evaluation. - CORRECT ANSWER Answer: B) Discuss barriers to compliance with the member. Resource: Rationale: The first step is to identify the barriers to compliance with the member in order to develop a plan to overcome the barriers. For example, a client who is non-compliant with his follow-up visits due to transportation issues can be referred to community resources for transportation. When the case manager becomes aware of a client's cultural or religious beliefs that conflict with the treatment plan the casemanager should: A) Close the client to case management, the case manager will not be able to benefit the client. B) Try to convince the client to disregard their beliefs, science has proven them wrong. C) Attempt to adjust the treatment plan to work within the cultural/religious limits. D) Educate the client on the scientific evidence for the treatment plan. - CORRECT ANSWER Answer: C) Attempt to adjust the treatment plan to work within the cultural/religious limits. Resource: Rationale: When the client's cultural beliefs conflict with the treatment plan, the case manager should attempt to adjust the treatment plan to work within the cultural limits. If this is not possible, the case manager must educate the client on the possible effects of not complying with the treatment plan. They should be done respectfully without coercing the client. Which of the following is not part of the case management process? A) Assess B) Report C) Coordinate D) Evaluate - CORRECT ANSWER Answer B) Although case managers may complete reports, and report to others, this is not part of the case management process. Reference CCMC's website defines case management as "a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs." Mr. Brown lives with his adult daughter and her husband. He tells the case manager that he has not taken one of his blood pressure meds in a week because he ran out and cannot afford to refill it. He goes on to state his checkbook is missing several checks, and his account is overdrawn. Mr. Brown is most likely: A) Suffering from dementia B) The victim of financial abuse C) The victim of elder abuse D) Making excuses for not taking his medications - CORRECT ANSWER Answer: B) The victim of financial abuse Resource Rationale: The elderly are at increased risk for abuse. The perpetrators of abuse are most often family members. Financial abuse includes the unauthorized use of resources. The health coach is working with a client in a smoking cessation program. The client makes the statement, "I have not had a cigarette in 9 months." The case manager knows the client is in which stage of change? A) Maintenance B) Action C) Preparation D) Contemplation - CORRECT ANSWER Answer: A) Maintenance Resource: Rationale: 5 Stages of Change 1. In the pre-contemplation stage, the individual does not intend to take action in the foreseeable future. 2. In the contemplation stage the individual considers a change in the next six months but has not committed to it. He may be open to information on the benefits of change and how to successfully do so. Rationale: Diagnosis-Related Group (DRG): A patient classification scheme that provides a means of relating the type of patient a hospital treats to the costs incurred by the hospital. DRGs demonstrate groups of patients using similar resource consumption and length of stay. It also is known as a statistical system of classifying any inpatient stay into groups for the purposes of payment. DRGs may be primary or secondary; an outlier classification also exists. Mrs. Cook lost her health insurance due to a reduction in work hours. She is eligible to received coverage under COBRA for how long? A) 18 months B) 29 months C) 36 months D) She is not eligible for COBRA - CORRECT ANSWER Answer: A) 18 months The health coach is working with a client in a hypertension program. The client makes the statement, "I know I need to make some changes in my lifestyle, I'm just not sure where to begin." The case manager knows the client is in which stage of change? A) Pre-Contemplation B) Action C) Preparation D) Contemplation - CORRECT ANSWER Answer: D) Contemplation Resource: Rationale: 5 Stages of Change 1. In the pre-contemplation stage, the individual does not intend to take action in the foreseeable future. 2. In the contemplation stage, the individual considers a change in the next six months but has not committed to it. He may be open to information on the benefits of change and how to successfully do so. 3. In the preparation stage, the client actively plans to make changes within the next month and may have taken small steps toward change. 4. Action is the stage when the individual has successfully made a change and has sustained it for less than six months. 5. When the individual has sustained the change for more than 6 months maintenance has been achieved. Which of the following is paid a fixed amount per member per month for contracted health care services in a geographical area to voluntarily enrolled group of people. A) PPO B) Workers' Compensation C) HMO D) Managed Care - CORRECT ANSWER Answer: C) HMO Resource: CCMC Glossary of Terms Rationale: Health Maintenance Organization (HMO): An organization that provides or arranges for coverage of designated health services needed by plan members for a fixed prepaid premium. There are four basic models of HMOs: group model, individual practice association (IPA), network model, and staff model. Under the Federal HMO Act an organization must possess the following to call itself an HMO: (1) an organized system for providing healthcare in a geographical area, (2) an agreed-on set of basic and supplemental health maintenance and treatment services, and (3) a voluntarily enrolled group of people. Medicare provides benefits to which of the following A) Patients who are disabled and not entitled to Social Security benefits B) Patients who are disabled and not entitled to Medicaid C) Patients who are disabled and entitled to Social Security benefits D) Patients who are not entitled to Social Security or Medicaid - CORRECT ANSWER Answer: C) Patients who are disabled and entitled to Social Security benefits Resource: Rationale: A person is entitled to Medicare based on disability after they have been entitled to Social Security Disability benefits for at least 24 months after a 5 month coordination period, for a total of 29 months. Resource Utilization Groups (RUG) and Minimum Data Sets (MDSs) are used to determine payment rates for which one of the following under Medicare? A) Skilled Nursing Facility (SNF) B) Inpatient rehabilitation C) Acute care hospitals D) Home health agencies - CORRECT ANSWER Answer: A) Skilled Nursing Facility Resource: Rationale: Resource utilization groups (RUGs) and minimum data sets (MDSs) are used to establish payment rates for skilled nursing facilities and determine reimbursement.The patient is assessed using the Minimum Data Set (MDS) assessment tool. Based on the MDS, the patient is placed into a RUG. The RUG determines the facility's reimbursement rate. A worker with Temporary Partial Disability (TPD): A) Is partially incapacitated for the length of the disability and unable to perform normal or modified work duties B) Is partially incapacitated for the length of the disability and is unable to perform normal work duties, but can engage in modified work C) Is totally incapacitated for work from the time of the injury, but is later able to return to work D) Has permanent partial loss of function that does not prevent work - CORRECT ANSWER Answer: B) Is partially incapacitated for the length of the disability and is unable to perform normal work duties, but can engage in modified work. Resource: Rationale: Temporary Partial Disability (TPD) - The worker is partially incapacitated for the length of the disability. Although unable to perform normal work duties, he or she may engage in modified work. Under Medicare which home health service is not a covered benefit? A) round the clock skilled nursing care B) intermittent skilled nursing care C) lab testing D) speech-language therapy - CORRECT ANSWER Answer: A) round the clock skilled nursing care Resource: Rationale: Under Medicare the home health services that are covered include intermittent skilled nursing care, lab testing, occupational therapy, physical therapy, respiratory therapy and speech-language therapy. Case managers use the motivational interview to: A) Motivate and inspire the client to make necessary changes. B) Help clients to explore and resolve ambivalence. C) Determine if the client is appropriate for case management. C) Retrospective Review D) Case Management Referral - CORRECT ANSWER Answer: C) Retrospective Review Resource: Rationale: Retrospective Review: A form of medical records review that is conducted after the patient's discharge to track appropriateness of care and consumption of resources. Concurrent Review: A method of reviewing patient care and services during a hospital stay to validate the necessity of care and to explore alternatives to inpatient care. It is also a form of utilization review that tracks the consumption of resources and the progress of patients while being treated. Prospective Review: A method of reviewing possible hospitalization before admission to determine the necessity and estimated length of stay. The main purpose of a concurrent review of a hospitalized patient is to: A) assess the need for continued hospitalization. B) assess for discharge planning needs. C) determine medical necessity for admission. D) screen for the need for case management. - CORRECT ANSWER Answer: A) assess the need for continued hospitalization. Resource: CCMC Glossary of Terms Rationale: Concurrent Review: A method of reviewing patient care and services during a hospital stay to validate the necessity of care and to explore alternatives to inpatient care. The main purpose is to assess the need for continued hospitalization as well as the level of care provided. For example, is ICU level of care required for this patient or can the care be provided on a lower level unit. Which of the following is used to examine the injured worker as he or she completes activities in a structured setting to identify the current level of function. A) Functional capacity evaluation (FCE) B) Functional independence measures (FIM) C) Instrumental activities of daily living (IADL) D) Job analysis - CORRECT ANSWER Answer: A) Functional capacity evaluation (FCE) Resource: CCMC Glossary of terms Rationale: Functional Capacity Evaluation (FCE): A systematic process of assessing an individual's physical capacities and functional abilities. The FCE matches human performance levels to the demands of a specific job or work activity or occupation. It establishes the physical level of work an individual can perform. The FCE is useful in determining job placement, job accommodation, or return to work after injury or illness. FCEs can provide objective information regarding functional work ability in the determination of occupational disability status. Which of the following statements is true regarding Medigap supplemental policies? A) Medigap is also known as Medicare part C. B) Medigap is offered by private insurance companies to Medicare recipients to cover out-of- pocket expenses. C) Medigap is a Medicare HMO. D) Medigap insurance covers individuals who do not qualify for Medicare. - CORRECT ANSWER Answer: B) Medigap is offered by private insurance companies to Medicare recipients to cover out-of- pocket expenses. Resource: Rationale: Medigap is offered by private insurance companies to cover out-of- pocket expenses. Medicare Part C a managed care option to obtain coverage for Parts A and B and sometimes D through a private health plan such as an HMO or PPO. The primary goal of work hardening is to: A) Improve the worker's endurance B) Return the employee to work C) Determine the maximum amount of work the employee can perform D) Identify accommodations to assist the employee - CORRECT ANSWER Answer: B) Return the employee to work Resource: CCMC Glossary of Terms Rationale: Work Hardening is a highly structured, goal-oriented, and individualized intervention program that provides clients with a transition between the acute injury stage and a safe, productive return to work. Treatment is designed to maximize each individual's ability to return to work safely with less likelihood of repeat injury. Work hardening programs are multidisciplinary in nature and use real or simulated work activities designed to restore physical, behavioral, and vocational functions. They address the issues of productivity, safety, physical tolerances, and worker behaviors. Case managers use the motivational interview to: A) Motivate and inspire the client to make necessary changes. B) Help clients to explore and resolve ambivalence. C) Determine if the client is appropriate for case management. D) Assess the clients phycological status. - CORRECT ANSWER Answer: B) Help clients to explore and resolve ambivalence. Resource: Rationale: The motivational Interview is a method that works on facilitating and engaging intrinsic motivation within the client in order to change behavior. The motivational interview is a goal-oriented, client- centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Which of the following pays for medical care for work related injuries? A ) Short Term Disability B ) Long Term Disability C) Workers' Compensation D) Employee health benefit - CORRECT ANSWER Answer: C) Workers' Compensation Workers' compensation pays for medical care for work-related injuries beginning immediately after the injury occurs. Which of the following statements is true of Third Party Administrators? A) They provide utilization review and process claims B) They collect premiums C) They are financially responsible for claims D) They provide medical care for enrollees - CORRECT ANSWER Answer: A) they provide utilization review and process claims Resource: CCMC Glossary of Terms Rationale: Third Party Administrator (TPA): An organization that is outside of the insuring organization that handles only administrative functions such as utilization review and processing claims. Third party administrators are used by organizations that actually fund the health benefits but do not find it cost- effective to administer the plan themselves. • Skille nursing facility stays • Home health care • Hospice care Case Management promotes what kind of outcomes? A) Those that can be obtained for the lowest cost B ) Quality and cost-efficient outcomes C) Patient determined outcomes D) Provider recommended outcomes - CORRECT ANSWER Answer B ) Quality and cost-efficient outcomes Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. To qualify for Supplemental Security Income (SSI) total assets (not including primary residence and one car) for a single person must be less than: A) $1,000 B) $2,000 C) $3,000 D) $5,000 - CORRECT ANSWER Answer: B) $2,000 Resource: Rationale: The total assets (not including primary residence and one car) must be less than $2,000 for an individual and less than $3,000 for a couple. Your client is considering a viatical settlement to help cover medical expenses. All of the following are true about viatical settlements except: A) The patient will be required by law to continue making the premium on the policy. B) The money received from a viatical settlement is usually free from federal income tax. C) The money received from a viatical settlement may impact eligibility for Medicaid. D) There are no restrictions on how the money received from a viatical settlement can be used. - CORRECT ANSWER Answer: A) The patient will be required by law to continue making the premium on the policy Resource: Rationale: The purchasing party becomes the beneficiary and takes responsibility for paying the premium. The money received from a viatical settlement is usually free from federal income tax but may impact eligibility for Medicaid. There are no restrictions on how the money received from a viatical settlement can be used. An indemnity insurance plan pays using what method: A) capitation B) fee-for-service C) per diem D) DRG - CORRECT ANSWER Answer: B) fee-for-service Resource: CCMC Glossary of Terms Rationale: Indemnity benefits usually pay after the provider has billed the patient, the insured person is reimbursed by the company. Also know as fee-for-service where providers are paid for each service performed, as opposed to capitation. Ms. Snow is a 55-year-old who was recently diagnosed with hepatitis C. Her doctor has prescribed an expensive drug to treat her disease. She has no insurance and is not eligible for Medicaid. She states to you that she is unable to afford the drug. Your initial step is to: A) Instruct the client to start a fundraiser to raise money for the drug. B) Suggest the client call the doctor and request other treatment options. C) Determine if the pharmaceutical company has a drug assistance program. D) Call the pharmacy and check if they can give the client a discount. - CORRECT ANSWER Answer: C) Determine if the pharmaceutical company has a drug assistance program. Resource: Rationale: Most drug companies have pharmaceutical assistance programs to assist those who are uninsured or underinsured to afford their medications. Each company determines the criteria for eligibility into the program. Raising the height of a desk to provide access by a wheelchair is an example of a: A) Job modification B) Job Accommodation C) Job restructuring D) Building Modification - CORRECT ANSWER Answer: B) Job Accommodation Resource: Rationale: Allowing an individual with a wheelchair to raise the height of their desk to accommodate the wheelchair is and example of a job accommodation. A job accommodation is focused on access for an individual. Other examples of job accommodations include voice recognition software and brail keyboards. Which of the following statements regarding Medicare Part D is not true? A) Medicare Part D provides subsidized access to prescription drug coverage. B) There is no premium to participate in Medicare Part D, only a small copay for brand name drugs. C) Medicare Part D pays for only part of the costs of prescription drugs. D) Medicare Part D is a voluntary benefit. - CORRECT ANSWER Answer: B) There is no premium to participate in Medicare Part D, only a small copay for brand name drugs. Resource: Rationale: Medicare Part D provides subsidized access to prescription drug coverage on a voluntary basis. Participants pay a premium and a portion of the cost of the drug. The case management process includes: A. Assessing, planning, implementing, coordinating, monitoring and evaluating. B. Quality Improvement, analysis, and monitoring. C. Contacting client, validating insurance, coordinating care and billing. D. Assessing, diagnosing, coordinating and utilization management. - CORRECT ANSWER Answer A Reference CCMC website: http://ccmcertification.org/.../definition-and-philosophy-cas... CCMC's website defines case management as "a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs." Using verbal insults, intimidation, or threats to withhold food as a means of getting an elderly patient to take their medication are examples of: A) Coercion B) Physical abuse C) Psychological abuse D) Acceptable methods to persuade the patient to take their medication. - CORRECT ANSWER Answer: C) Psychological abuse