CCM Test practice 1 questions with answers 2023, Exams of Nursing

Download CCM Test practice 1 questions with answers 2023 and more Exams Nursing in PDF only on Docsity! CCM Test practice 1 questions with answers 2023 Tools to identify patients who might benefit from disease management include all except a. ICD 9 b. CPT codes c. utilization data d. radiology data ✔d. radiology data Which is not included as one of the three major elements that are globally accepted to achieve health and wellness a. knowledge b. to be in a position to chose better health c. the empowerment to make decisions and sick to those decisions d. money ✔d. money If a case manager is working with a home health agency within a managed care network and there is a complaint regarding the quality of the staff they are sending, the case manager should first address the complaint with a. accrediting agency that oversees the managed care agency b. quality department within the managed care organization c. home health agency director of nurses d. risk department ✔b. quality department Social service agencies may differ from volunteer organizations because a. they usually require the patient to meet certain eligibility requirements not required by most voluntary organizations b. they charge a fee, while volunteer agencies are free c. they are financed with state funds, while volunteer agencies are financed with federal funds d. volunteer organizations are more loosly structured. ✔a. they usually require the patient to meet certain eligibiity criteria not required by volunteer organizations Which heath assessment screening tool would be a common choice when assessing the chronic alcoholic patient a. ROSE b. SF 36 c. BASIS 32 d. OASIS ✔C. BASIS ROSE-cardiac disease, SF 36 - health assessment screening tool, OASIS-not used as a health too-used in home health The 80-20 rule demonstrates a. that there is a direct ratio between health care spending and the risk population that uses health care resources b. that supervisors have a way to determine case management case load c. the ratio between insured and uninsured d. the ratio of those covered by private insurance and those covered by managed care organizations ✔a. the ratio between health care spending and the at risk population using health resources The mother of a diabetic child tells the case manager that her son is not sticking tot he diet and has had high sugar levels over the past week and has missed school. The case manager uses what skills to address the problem a. negotiation b. conflict resolution c. consultation d. accountability ✔b. conflict management The case manager working in the provider setting whose role is to ensure that resources are used in an appropriate manner for the payer and the provider may be found in which setting a. hospital b. managed care organization c. professional organization d. credentialing organization ✔a. hospital In a stated contract used by the provider delivering services, it is implied that a. cost will be competitive b. quality will be assured c. confidentiality will be maintained d. the provider will be paid for services rendered ✔d. the provider will be paid for services rendered The first phase of the case management process is a. patient identification and referral b. examination of the benefits and limitations c. assessment of the patient d. development of the treatment plan In a viatical settlement, how much the insurance company will pay the viator is usually determined by a. determonation by the life-care planner b. viator's living will c. amount negotiated by the viator d. the life expectancy of the viator ✔d. the life expectancy of the viator When calling the managed care utilization management specialist to obtain authorization for an elective hysterectomy, the acute care case manager must provide what information a. complete medical record detaining the patient's history of severe cramping and intensive bleeding episodes b. diagnostic testing that supports the need or the hysterectomy c. written order from the surgeon who will perform the surgery d. signed consent form showing the pt has agreed to the procedure ✔b. diagnostic testing that supports the need or the hysterectomy A MD has decided that a bone marrow transplant is the treatment of choice for a 38y/o woman with breast cancer. He received a denial from the woman's HMO. He feels he has the supporitn documenttion for the procedure. what is the next step the MD should take a. file a quick claim lawsuit gainst the insurance company b. send a letter to the state insurance commission c. inform the patient that she should submit a grievance against the HMO d. file an appeal with the HMO with supporting documentation that justifies the procedure ✔d. file an appeal with the HMO with supporting documentation that justifies the procedure Outcomes that are anticipated from utilization management and case management are a. an increase in the credentials of professional staff b. better use of resources, containment of cost, and quality health care delivery c. a decrease in health care cost from administrative overlap decrease d. the creation of a new accrediation body to oversee the new model of care coordination ✔b. better use of resources, containment of cost, and quality health care delivery Weight reduction programs that are geared to children strive to a. encourage weight loss b. point out poor eating habits. c. encourage parents to control the child's diet. d. boost self esteem and communication skills ✔d. boost self esteem and communication skills The primary goal of disease monitoring is to a. reduce the amount of calls that the treating MD receives due to complications of chronically ill pts. b. make the pt aware of any changes that require hospitalization, and discern minor changes that can wait for a regular office visit c. educate the patient to report all positive and negative changes, for accurate monitoring d. inform the pt that if there are more than 3 admissions to the hosp the pt will be drop from disease monitoring ✔c. educate the patient to report all positive and negative changes, for accurate monitoring The symptoms of restrictive lng disease include all of the following EXCEPT a. reduction of air volume, capacity and noncompliant lungs b. narrowing of airways c. inadequate oxygenation of hemoglobin d. the ability to exhale a large tidal volume ✔d. the ability to exhale a large tidal volume A living will designates a. whether the pt MD has the authority to make treatment decisions in the event the pt is unable b. whether an individual desires life prolonging treatment in the event they are unable to make medical decisions. c. whether advance directives are necessary d. whether accelerated death benefits are available to the partner ✔b. whether an individual desires life prolonging treatment in the event they are unable to make medical decisions. Title III of the Americans with Disabilities Act is federally enforced by the a. Department of Justice b. EEOC c. Architectural and Transportation Barriers Compliance Board d. Department of Veterans Affairs ✔a. Department of Justice The Health Information Portability and Accountability Act (HIPAA) provides a. opportunity for an employee to accept a new job and maintain his former group health insurance for 62 days max b. capability for an employer to exclude a new employee from the group health plan if he employee has a significant health history c. capability for an employee to move to a new health plan without denial or exclusions of benefits if there is no breach in group health coverage exceeding 62 days d. opportunity for an employee to accapt a new job and maintain his former group health insurance for 18 months. ✔c. capability for an employee to move to a new health plan without denial or exclusions of benefits if there is no breach in group health coverage exceeding 62 da The Family and Medical Leave Act of 1993 allows for a. unpaid leave for up to 6 months for eligible employees b. benefits received by an employee during illness to be treated as nontaxable income c. paid leave for up to 16 weeks for eligible employes d. unpaid leave for up to 12 weeks for eligible employees ✔d. unpaid leave for up to 12 weeks for eligible employees Subrogation is defined as a. the legal process by which and insurance company seeks from a third party who has caused a loss, recover of the amount paid b. the insurance process where coordinated health payments are made by two or more benefits plans c. the insurance process wherre a health care beneficiary can receive out of benefit services if a cost benefit analysis is done d. legal process where a heath care plan beneficiaries can recap out of pocket expenses ✔a. the legal process by which and insurance company seeks from a third party who has caused a loss, recover of the amount paid An HMO primary goal is to a. limit choices in the treatment plan b. enhance cost savings through limitation of benefits c. enhance the quality care through a coordinated network d. limit the policy holder's selection of a primary care MD ✔c. enhance the quality care through a coordinated network Under the 'own occupation' rule in disability insurance, a person can a. file a claim of wage loss disability based on an inability to perform all aspects of the person's job b. file a claim of wage loss disability based on an inability to perform any one aspect of the person's job c. rewrite his own job description to modify aspects of the job he can perform d. sue the employer for the right to return to his own occupation ✔b. file a claim of wage loss disability based on an inability to perform any one aspect of the person's job Protecting patient confidentiality respects the patient's right to a. self esteem b. self determination a. public access requirements for all retail businesses b. required access for all forms of public transportation c. rights of disabled individuals t5o receive rehabilitation treatment, regardless of their ability to pay d. civil rights of all persons with disabilities ✔d. civil rights of all persons with disabilities In the past fee-for-service environment, health care services were a. reactive oriented-based on illness and injury b. wellness oriented-based on preventative care c. economically oriented-based on capitated cost d. patient oriented-based on advocacy ✔a. reactive oriented-based on illness and injury When an injured worker is receiving workers compensation benefits. Medicare benefits are a. primary b. not applicable c. secondary d. reduced in accordance with theResource Based Relative Value Scale ✔c. secondary Advance directives are aso known as a. accelerated dealth benefits b. living wills c. the Patient Self Determination Act d. viatical settlement ✔b. living wills Reporting of abuse is a. mandatory in all 50 states b. mandatory in many states c. at the discretion of the health care provider d. a matter to be handled by law enforcement ✔b. mandatory in many states 1. Of the following, which are common causes of malpractice litigation? 1. Discourteous behavior by the professional 2. Provider/patient miscommunication 3. Lack of patient understanding 4. Failure to inform a patient's family of pertinent issues A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D) All of the above 2. Case Managers may decrease the legal liability associated with patient discharges through which of the following activities? 1. Reviewing the case with the treating physician 2. Confirming the integrity of the patient's support network 3. Reviewing the complete medical record 4. Confirming the adequacy of follow-up outpatient care A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D Response: The Case Manager has an obligation of "reasonable care" to the patient. Failing to ensure that the discharge is "safe" would be negligent on the part of the Case Manager. 3. Disclosure of confidential information is mandatory when: A) It is pursuant to judicial proceedings. B) It is government mandated. C) A professional has a duty to warn a third party about the illness of a patient. D) All of the above E) None of the above ✔D 4. Which of the following statements are consistent with the findings of the court case of Wickline v. State of California? 1. Medical doctors have a duty to protest adverse determinations by payers. 2. Medical doctors can shift their liability to payers if they do protest adverse determinations. 3. Payers of heath care can be held accountable, if their adverse decisions are arbitrary, for cost containment and are not based on acceptable medical standards of practice in the community. 4. Case Managers are not liable for their roles in adverse determinations A) 1, 2, 4 B) 2, 3, 4 C) 1, 2, 3 D) None of the above ✔C Response: Case Managers are liable for damages if their referral of patients to providers is negligently performed and harm comes to the patient as a direct result of that referral. 5. Which of the following statements best defines ethics, as it relates to case management? 1. The rules of conduct that govern a person, or members of a profession 2. The thoughts that govern a person's conduct 3. A society's ideal for a person's conduct 4. The minimal acceptable standards for a person's conduct A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above All of the above E) None of the above ✔D Which of the following diagnoses should trigger an inquiry for potential case management services? 1. Blepharitis 2. Spinal cord injury 3. Coryza 4. Non-Hodgkin's lymphoma A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) ✔B Both spinal cord injuries and lymphomas are complex, high-cost, and life-threatening illnesses that may potentially benefit from case management. Coryza is a common cold, and blepharitis is a minor infection of the eyelid. 11. Which of the following are "sentinel procedures" that should prompt inquiries for case management services? 1. Brain biopsy 2. Bone marrow biopsy 3. Endocardiac biopsy 4. Skin biopsy A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔C Although biopsies of the endocardium, the brain, and bone marrow involve high risk and are done infrequently, biopsies of the skin are low risk, are commonly performed, and require case management services in a small minority of cases. 12. Of the following, which utilization figure for an individual's medical claims would make an appropriate financial threshold for case management evaluations? A) Claims exceeding $500 per year B) Claims exceeding $1,000 per year C) Claims exceeding $10,000 per year D) Claims exceeding $100,000 per year E) Claims exceeding $1,000,000 per year ✔C Screening all patients with claims over $500 and $1,000 per year would yield too many claims and too few catastrophic illnesses. Those patients with claims of $100,000 and over would no doubt be well-known to the insurers and Case Managers long before the patients hit those thresholds. Thresholds of $5,000 to $10,000 are most commonly seen in the industry. 13. Which of the following is needed in order for the Case Manager to ensure an accurate assessment of the impact an injury will have on a patient and his or her ability to return to work? A) The physical requirements of the patient's position B) The coworkers'/employer's opinion of the patient's ability C) History of childhood diseases D) All of the above E) None of the above ✔A To make an accurate determination in regard to a patient's ability to return to work, the Case Manager and the team involved in the care of the patient must know the physical requirements of the patient's job. Which of the following statements are true regarding the clinical consequences of head injuries? 1. A patient may become depressed. 2. A patient's cognitive ability may be impaired. 3. Emotional lability is common. 4. Chronic headaches may result. A) 1, 3 B) 1, 2, 4 C) 1, 2, 3 D) All the above E) ✔D 15. Of the following methodologies, which are common means that insurers and Case Managers use to identify potential patients for case management services? 1. Selecting cases with catastrophic diagnoses, such as head or spinal injuries 2. Selecting cases with "sentinel procedures," such as bone marrow biopsy or brain biopsy 3. Selecting cases with claims costs of more than $10,000 a year 4. Selecting cases at random and investigating for potential problems A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔C Common methodologies include screening claims of catastrophic diagnoses, sentinel procedures, high-claims cost, and direct case referral from community physicians. A variety of cognitive techniques may be utilized for pain control. Which of the following are examples of these techniques? 1. Distraction 2. Pain medication 3. Relaxation training 4. Biofeedback A) 3, 4 B) 1, 2, 3 accommodation's expense for an employer does not automatically make it a "hardship."). 22. Under the proscriptions of the Americans with Disabilities Act, which of the following are not considered "reasonable accommodations" by the employer? 1. Making the disabled "typist" a receptionist who answers phones only 2. Modifying equipment to accommodate disabled employees 3. Making the paralyzed "ballet dancer" a "theatrical director" of the ballet company 4. Providing qualified interpreters for the hearing impaired A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Response: The employer is obligated to make "reasonable accommodations" to an individual's disability that allows the employee to perform his job. Reasonable accommodations in employment may include: - Making existing facilities readily accessible to and usable by an individual with disabilities - Job restructuring, part-time or modified work schedules, reassignment to a vacant position - Acquiring or modifying equipment or devices - Appropriately adjusting or modifying examinations, training materials, or policies - Providing qualified readers or interpreters, and other similar accommodations for individuals with disabilities In the previous examples, the individual hired as a typist must be able to type, similarly, a ballet dancer must be able to dance; changing the essential job function, although laudatory, is not mandated by the ADA. 23. Which of the following statements are true, regarding the Women's Health and Cancer Rights Act? 1. It is a law enacted as part of the Omnibus Appropriation Bill. 2. It ensures coverage for surgery of the contralateral breast to provide a symmetrical appearance after mastectomy. 3. It amended ERISA to require both health plans and self-insured plans to provide coverage for mastectomies and certain reconstructive surgeries. 4. It ensures coverage for breast prostheses after mastectomy. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D Response: The Women's Health and Cancer Rights Act is a law that was enacted as part of an Omnibus Appropriation Bill and became effective for plan years beginning on or after October 21, 1998. This Act amended ERISA to require group health plans, including self-insured plans, which provide coverage for mastectomies, to provide certain reconstructive and related services following mastectomies. The services mandated by the Act include: - Reconstruction of the breast upon which the mastectomy has been performed - Surgery and reconstruction of the other breast to produce a symmetrical appearance - Prosthesis and treatment for physical complications attendant to the mastectomy, for example, lymphedema 24. Which of the following statements are true regarding unemployment insurance? 1. Financing of unemployment benefits are uniform from state to state. 2. Unemployment compensation benefits guarantee a replacement of 50% of salary. 3. Benefits are never extended past the usual maximum length of benefit. 4. All states pay a minimum of 46 weeks of unemployment benefits. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔E Response: State financing and benefit laws vary widely. In general, unemployment compensation benefits under state laws are intended to replace about 50% of an average worker's previous wages. Maximum weekly benefits provisions, however, result in benefits of less than 50% for most higher-earning workers. All states pay benefits to some unemployed persons for 26 weeks. In some states, the duration of benefits depends on the amount earned and the number of weeks worked in a previous year. In others, all recipients are entitled to benefits for the same length of time. During periods of heavy unemployment, federal law authorizes extended benefits, in some cases up to 39 weeks; in 1975, extended benefits were payable for up to 65 weeks. Extended benefits are financed in part by federal employer taxes. 25. Which of the following is(are) true regarding Worker's Compensation Insurance? 1. The scope of coverage varies from state to state. 2. Benefits generally include the cost of legal bills only. 3. Employees are entitled to the level of benefit mandated by the state. 4. Self-funded health insurance programs are exempt from the mandates of workers' compensation regulations. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Response: The scope of coverage for workers' compensation benefits varies by state, with respect to benefits payable in case of death, of total disability, and of partial disability due to specific injuries or continuing during specified periods. Although they vary among states, these benefits generally include the cost of medical bills attendant to treating the illness or injury, as well as some percentage of lost wages. The compensation benefits, set forth by the state, take precedence over the funding source. Employees are entitled to the level of benefits mandated by the state without regard to the financial status or desires of the employer. Therefore, even if the employer is self-funded or self-administrated, he is required to offer the full level of benefits required by the state's workers' compensation commission. Self-funded group health insurance plans may be exempt from mandated benefits under ERISA guidelines but are not exempt under Worker's Compensation regulations. 26. Which of the following statements about indemnity health insurance plans is(are) not true? D) All of the above E) ✔A Response: Although its scope is large, the Pregnancy Discrimination Act does exclude some benefits. Those benefits are abortions and mandatory maternity leave. When home health and home physical therapy are allowed under medical benefits, they are included under maternity benefits also Which of the following mental health benefit limitations are not allowable under the tenets of the Mental Health Parity Act? 1. Annual dollar limit for mental health care 2. Limited number of annual outpatient visits 3. Lifetime dollar limit on mental health care 4. Limited number of inpatient days annually A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Response: Although annual or lifetime dollar limits cannot be set under the provisions of the Mental Health Parity Act, other limits are allowed. Examples of other allowable limits are: - Limited number of annual outpatient visits - Limited number of inpatient days annually - A per-visit fee limit Higher deductibles and copayments are allowed in mental health benefits under MHPA, without parity in medical and surgical benefits. If an employer does not offer medical benefits, he does not have to offer mental health benefits; said differently, if an employer chooses not to offer mental health benefits, he must also choose not to offer medical benefits. 31. CCMC defines case management as a process involving which of the following? 1. Managed care 2. Assessing, planning, and monitoring 3. Collaboration, coordination, and communication 4. Implementation and evaluation A) All of the above B) None of the above C) 1, 2, 3 D) 2, 3, 4 ✔D 32. Which of the following answers are not included in the six core areas of case management? A) The return-to-work process B) Case management concepts C) Healthcare management and delivery D) Vocational concepts and strategies ✔A Response: The return-to-work process (RTW) is part of workers' compensation case management, not a core component of case management. The six core areas consist of B, C, D, psychosocial intervention, processes and relationships, and rehabilitative case management. 33. Case finding, gathering and assessing information, and problem identification are all part of: A) Patient advocacy B) The return-to-work assessment C) The case management process D) The precertification process ✔C Response: These are all part of the case management process, which also includes planning, reporting, obtaining approval, coordination, follow-up, monitoring, and evaluation 34. Diagnosis, high costs, and multiple admissions or treatments are red flags for: A) Preexisting HMO exclusions B) Utilization management review C) Case management evaluation D) Disability hearings ✔C Response: These are the three criteria for case management referrals 35. The Case Manager never contacts: A) The patient B) The caregivers C) The employer D) The patient's coworkers ✔D Response: The first three choices are involved in the patient's care or benefit payment. The caregivers are contacted for the assessment of the patient and his progress. The employer is contacted for approval of benefit plans or return-to-work information. The patient is contacted to collaborate with the Case Manager on his care plan. 36. A case management consent agreement provides for which of the following? 1. Release of clinical information to the Case Manager 2. Claims payment 3. Permission to review the case information with the parties involved in the care of the patient or the payment of services Which of the following is true regarding a prosthesis? 1. It may restore or replace all or part of a missing body part. 2. It may improve a person's sense of wholeness or body image. 3. It has as its goals increased function and cosmesis. 4. It may result in injury or illness if improperly fitted. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D Response: A prosthesis is a device that restores or replaces all or part of a missing body part. The science of prosthetics addresses the mechanical, physiologic, and cosmetic functions of restorations. Orthoses, on the other hand, are aimed at assisting the body to restore function, prostheses restore or replace those parts of the human body that are absent or no longer function. The need for replacement and cosmesis rather than a simple increase in functionality stems from a person's need for "wholeness" and a "positive body image." With this in mind, the professional prosthetist has as his or her goals, increasing both functionality and cosmesis. Poorly fitted prostheses can cause injury or illness. Which of the following is true regarding assistive devices? 1. They are products that substitute for an impaired function. 2. They are a substitute for rehabilitation services. 3. They allow an individual to perform an activity more independently. 4. When prescribing one, little input is needed from the patient or patient's family. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Response: Assistive or adaptive devices are products that substitute for an impaired function and allow the individual to perform an activity more independently. Adaptive devices should be used only if other methods of performing the task are not available or cannot be learned. A reasonable effort should be made to teach the patient a method of performing the task in question, before an adaptive device is suggested. Mastery of a task, for example walking, allows the patient greater independence and flexibility in that he does not need a wheelchair to move around and is not limited by lack of ramps, and so on. The device may serve as a useful supplement, however, or permit a function to be performed if the adapted method cannot be learned or requires too much effort. The type of assistive device is determined by the needs of the individual patient, his abilities and functional limitations, and his environment. 44. Which of the following factors may influence the rate of prosthesis replacement? 1. Activity level 2. Age of user 3. Type of prosthesis 4. Impact resistance of materials used A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D Response: Many factors influence replacement frequency. For example, lower extremity prostheses bear weight, sustain high impact, and are exposed to the elements. Damage to the prostheses acquired by these activities demands maintenance, repair, and replacement. Replacement frequency depends on the activity level of the patient and the demands he or she puts on the prosthesis as well as the complexity of the prosthesis and the properties of the materials used. Further, an individual's prosthetic needs may change. For example, a sedentary individual may become more active, requiring a new prosthesis with more features and flexibility. Conversely, an active individual, with advancing age or disease may become more sedentary, requiring a replacement prosthesis that is lighter and more stable. Finally, the younger patient will require successively larger prostheses to compensate for growth. 45. Which of the following are(is) considered an assistive device? 1. Text-to-speech synthesizer 2. Phone receiver volume control 3. Quad cane 4. Grab bars in the tub A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D 46. The three basic goals of a patient interview are to: 1. Provide information. 2. Establish rapport. 3. Provide a care plan. 4. Collect information. 5. Formulate a care plan. A) 1, 2, 3 B) 2, 3, 4 C) 1, 4, 5 D) 2, 4, 5 ✔D Response: Providing information is not one of the basic goals of the interview. Providing a care plan does not allow the patient to be an active participant in the care-planning process. 47. When the Case Manager is arranging for discharge to a traumatic brain injury (TBI) rehabilitation facility, he or she should: 1. Confirm that the facility can provide the therapies, by credentialed providers, that the patient requires. 2. Verify that there is a board-certified medical director at the facility. ✔A Case management documentation should: 1. Be completed upon closure of the case 2. Be completed as close to the time of all contacts as possible 3. Be thorough 4. Reflect the patient's level of involvement in care planning A) 1, 2, 3 B) 1, 3, 4 C) 2, 3, 4 D) All of the above ✔D Assessment, planning, implementation, coordination, monitoring, evaluation, outcomes, and general are referred to as: A) The nursing process B) The scientific method C) The eight essential activities of case management D) None of the above ✔C Accurate and thorough case management documentation: A) Limits or reduces liability B) Is a legal medical record subject to state record retention laws C) Is confidential D) None of the above E) All of the above ✔E The role of the Case Manager is that of: A) Educator, facilitator, insurance advocate B) Assessor, planner, educator, facilitator, patient advocate C) Claims adjuster, planner, educator, facilitator D) Assessor, medical planner, facilitator ✔B Case finding, gathering, and assessing information and problem identification are all part of: A) Patient advocacy B) The return-to-work assessment C) The case management process D) The precertification process ✔C Diagnosis, high costs, and multiple admissions or treatments are red flags for: A) Preexisting HMO exclusions B) Utilization management review C) Case management evaluation D) Disability hearings ✔C The Case Manager never contacts: A) The patient B) The caregivers C) The employer D) The patient's coworkers ✔D Which of the following is not true about case management? A) It is a new profession. B) It is an area of practice within one's profession. C) It is performed by a variety of healthcare providers. D) It is performed in a variety of settings. ✔A Case Managers work in a variety of settings. Which of the following are examples of the provider sector? 1. Third-party administrators 2. Infusion company 3. Rehabilitation center 4. Hospital A) 1, 2, 3 B) 2, 3, 4 C) None of the above D) All of the above ✔B Case Managers perform their function in the following four areas: medical, financial, vocational, and _____________. A) Workers' compensation B) Social C) Legal D) Behavioral/motivational ✔D Although Case Managers work in a variety of settings, they all have a common denominator of patient advocacy, educating patients, and facilitating the patients' optimal outcomes. But the focal point of their work is: A) Empowering physicians to be gatekeepers B) Empowering patients to be active decision makers in their health care C) Mandating care plans to patients and their families D) Mandating services to be provided by their physicians ✔B Case Managers deal with vocational activity most often in a: A) Subacute setting B) Acute care facility C) Rehabilitation center D) None of the above ✔C Continual assessment of the care plan is part of which process(es)? A) Initial evaluation B) Goal setting C) Implementation D) Monitoring and evaluation ✔D The following information should be included in which report? - Desired outcomes - Progress toward outcomes - Cost without case management intervention - Cost with case management intervention - Savings due to case management intervention A) Cost/benefit analysis reports B) Patient case reports C) Summary reports D) Vendor progress reports ✔B The CMSA states that nationally the typical savings for every $1 spent on case management services are: A) $3-$5 B) $5-$7 C) $10-$12 D) $15-$18 ✔A Which of the following is(are) true regarding client cost/benefit analysis reporting? ✔E Reports that demonstrate case management savings to the payer of services in terms of dollars spent as compared to dollars saved are: A) Outcome reports B) Cost/benefit analysis reports C) Case closure reports D) Claims reports ✔B Identification of potential high-risk or high-cost patients is known as: A) Case finding and targeting B) Planning C) Gathering and assessing information D) None of the above ✔A During the ______________________, the Case Manager determines how the family members see their role. A) Implementation phase B) Initial assessment C) Referral process D) All of the above ✔B In evaluating a medical plan, what are the main considerations? 1. Quality of life 2. Number of treating providers 3. Quantity of money spent on health care 4. Progress of patient A) 1, 2, 3 B) 1, 3, 4 C) All of the above D) None of the above ✔B The process of case management includes which of the following categories? 1. Case finding and targeting 2. Planning, reporting, and obtaining approval 3. Gathering and assessing information 4. Coordination, follow-up, and evaluation A) 1, 2, 3 B) 2, 3, 4 C) All of the above D) None of the above ✔C Items that a Case Manager should review in his or her initial assessment are: A) Vocational status B) Leisure activities C) Socioeconomic and psychological factors D) All of the above ✔D Case management is: A) A way of reducing costs B) A method of following the referral source instructions C) A profitable business D) 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. ✔D The focus of case management is to: A) Save money B) Report to the referral source C) Empower patients D) All of the above ✔C The Case Manager needs to keep the referral source informed regarding: A) Total case management charges B) Case management interventions and outcomes C) Large cases in terms of money and time D) All of the above ✔D A Case Manager's records should be scrupulously accurate, unbiased, and completed in a timely fashion because: A) Orderliness of records is scored by state inspectors during reviews, and, therefore, can affect state reimbursement rates. B) A client may become involved in litigation that may require the testimony or written records of the Case Manager. C) A Case Manager's records have an impact on the policy limits of PIP coverage. D) All of the above E) None of the above ✔B After a case management plan is implemented, the Case Manager should: 1. Monitor compliance and communicate noncompliance to the treating physician. 2. Always arrange for a second opinion to determine if the treatment plan is medically necessary. 3. Monitor the patient's progress and change the patient's goals as necessary. 4. Cancel the physician's orders if the insurer disagrees with the care plan. A) 1, 2 B) 1, 3 C) 1, 2, 3 D) All of the above E) None of the above ✔B The Case Manager can facilitate the treatment plan ordered by the physician and the patient's recovery by: 1. Facilitating approval for all authorizations required 2. Arranging for all medically necessary services in a timely fashion 3. Evaluating the effectiveness of the services or care plan on a regular basis 4. Communicating with the providers of services and the physician regularly and as needed 5. Providing hands-on care when needed A) 1, 2, 3 B) 2, 3, 4 C) 1, 2, 3, 4 D) All of the above E) None of the above ✔C The effectiveness of the entire case management process depends on which of the following? 1. Physician cooperation 2. Patient cooperation 3. Obtaining an accurate history 4. Family cooperation A) 1, 2 B) 1, 2, 3 C) 1, 3 D) All of the above E) None of the above ✔D To assess the appropriateness of the treatment plan, the Case Manager should: A) 1, 2, 3, 4 B) 1, 2, 3, 5 C) 1, 2, 4, 5 D) All of the above E) None of the above ✔B __________________ is a systematic process of data collection and analysis involving multiple components and sources. A) Assessment B) Evaluation C) Implementation D) Planning ✔A Which of the following diagnoses should trigger an inquiry for potential case management services? 1. Blepharitis 2. Spinal cord injury 3. Coryza 4. Non-Hodgkin's lymphoma A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Of the following, which are "sentinel procedures" that should prompt inquiries for case management services? 1. Brain biopsy 2. Bone marrow biopsy 3. Endocardiac biopsy 4. Skin biopsy A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔C Of the following, which utilization figure for an individual's medical claims would make an appropriate financial threshold for case management evaluations? A) Claims exceeding $500 per year B) Claims exceeding $1,000 per year C) Claims exceeding $10,000 per year D) Claims exceeding $100,000 per year E) Claims exceeding $1,000,000 per year ✔C Of the following methodologies, which are common means that insurers and Case Managers use for identifying potential patients for case management services? 1. Selecting cases with catastrophic diagnoses, such as head or spinal injury 2. Selecting cases with "sentinel procedures," such as bone marrow biopsy or brain biopsy 3. Selecting cases with claims costs over $10,000 in a year 4. Selecting cases at random, and investigating for potential problems A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔C The primary goals of medical case management include all of the following except: A) To ensure the effectiveness of medical treatment and that rehabilitative services are arranged for in a timely and progressive manner B) To assist in cost containment C) To minimize the recovery period without jeopardizing medical stability or quality of care D) To provide hands-on nursing care ✔D Which of the following choices best defines negotiation? A) The action or process of communication whereby two or more parties advance mutual interests and reconcile differences to achieve a common goal or solve a common problem B) The process of reciprocally voicing demands C) The process of communication whereby two or more parties attempt to gain advantage in a dispute D) The action whereby two or more parties contest a mutually sought after goal ✔A Which of the following choices is the most important thing to have in a negotiation? A) Physical presence B) Financial advantage C) Information D) Influence in the business community ✔C The acronym BATNA is best defined by which of the following? A) Business Aptitude Training for Negotiators in America B) Business Attitude Testing for Negotiators in the Americas C) Best Answer in Negotiated Alliances D) Best Alternative to a Negotiated Agreement ✔D Which of the following is not true of BATNA? A) BATNA is an exercise in imagination and research. B) BATNA should occur before any substantive negotiation. C) BATNA is an exploration of what happens when there is a negotiation impasse and no agreement can be reached. D) BATNA allows you to beat the other party at its own game. ✔D Which of the following is not considered necessary in most negotiations involving Case Managers? A) Respect between the parties B) Trust and trustworthiness C) Team negotiation D) Information ✔C Which of the following does not characterize the end of an unsuccessful negotiation? A) One or more aggrieved parties B) A "winner" and a "loser" C) A tendency toward conflict in the future D) A situation in which both parties have benefited and increased their opportunities for profitable business relations in the future ✔D Which of the following is an example of active listening during a negotiation? A) "Okay, I've heard your side, now listen to what I've got to say!" B) "Yeah, yeah, yeah, but what about my issues?" C) "You've mentioned quality of service twice now. Do you want to give me some examples of what good quality means to you?" D) "Hey, when do I get a chance to air my grievances?" ✔C An "irritator" in the setting of a negotiation, is best described by which of the following? A) Any physical action by one party that the other party finds annoying, such as sneezing or scratching. 4. The names of all the patients the provider has treated with this intervention in the past A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Which of the following are requirements for obtaining informed consent? 1. The patient must consent voluntarily. 2. The patient must have the capacity to give consent. 3. The patient must be an adult (under existing state law). 4. In the event that the patient is a minor, or adult without capacity to consent, parents, attorneys, or legal guardians may give consent. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D In order to decrease patient allegations of lack of informed consent, a Case Manager should ensure which of the following? 1. The patient must have a full understanding of the scope of activities of the Case Manager, with all its attendant risks, benefits, and alternatives. 2. The Case Manager must document the consent. (A signed consent agreement is adequate.) 3. The Case Manager must obtain informed consent prior to the beginning of the professional relationship. 4. The Case Manager must consult with an attorney before every consent for treatment is signed. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔C Which of the following are not requirements for obtaining informed consent? 1. The attorney must sign an affirmation stating that the patient is competent. 2. The patient must have the capacity to give consent. 3. The patient must be at least 10 years of age. 4. In the event that the patient is a minor, or adult without capacity to consent, parents, attorneys, or legal guardians may give consent. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following are requirements for obtaining informed consent? 1. The patient may consent voluntarily or may be coerced if uncooperative. 2. The patient must have the capacity to give consent. 3. The patient must be an adult; however, emancipated minors must have their parents' consent. 4. In the event that the patient is a minor, or adult without capacity to consent, parents, attorneys, or legal guardians may give consent. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B A case management consent agreement provides for which of the following? 1. Release of clinical information to the Case Manager 2. Claims payment 3. Permission to review the case information with the parties involved in the care of the patient or the payment of services 4. Provision of durable medical equipment A) 1, 2 B) 2, 3 C) 1, 3 D) 3, 4 ✔C In the case management process, the stage of "obtaining approval" refers to: A) Permission from the patient to implement case management B) Permission from the payer to implement a care plan C) Permission from claims to negotiate fees D) None of the above ✔B Informed consent must contain which of the following elements? 1. Disclosure of all possible side effects 2. Disclosure of meaningful background information 3. A chance for the patient to ask questions 4. It must be done by an RN. A) 1, 2, 3 B) 2, 3, 4 C) 2, 3 D) All of the above ✔C Negotiated services and verbal agreements with vendors of medical equipment or services should be confirmed in writing and include which of the following? A) Time frame of the negotiation B) Service approved, number of units approved, frequency approved C) Fees negotiated (itemized) D) B, C E) All of the above ✔E Obtaining an accurate history is important to the case management process. Toward that end, the Case Manager should: 1. Obtain a signed consent agreement or release of medical information from the patient. 2. Obtain the history directly from the patient. 3. Interview the employer. 4. Request medical records for review. 5. Interview the physician. A) 1, 2, 3 B) 1, 2, 3, 4 C) 1, 2, 4, 5 D) All of the above E) None of the above ✔C When conducting an interview to obtain an accurate history, after a work-related accident, which of the following is(are) essential? 1. Investigating the legal issues of the accident 2. Current treatment and medications 3. Employment history and job requirements 4. Description of the accident 5. Previous medical history A) 1, 2, 3, 4 B) 2, 3, 4, 5 C) 3 only D) All of the above ✔C Of the following, which are common causes of malpractice litigation? 1. Discourteous behavior by the professional 2. Provider/patient miscommunication 3. Lack of patient understanding 4. Failure to inform a patient's family of pertinent issues A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D Of the following, which are not common causes of malpractice litigation? 1. Discourteous behavior by the professional 2. Poor clinical outcomes 3. Lack of patient understanding 4. Substandard medical care A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Common causes of malpractice litigation include which of the following? 1. Discourteous behavior by the professional 2. Poor clinical outcomes 3. Lack of patient understanding 4. Substandard medical care A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Case management activities that have the highest risk of malpractice associated with them include which of the following? 1. Patient discharge 2. Claims denials 3. Patient assessment 4. Referral to providers A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D Of the following case management activities, which do not have the highest risk of malpractice associated with them? 1. Patient admissions 2. Patient assessment 3. Claims approvals 4. Referral to providers A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Case Managers may decrease the legal liability associated with patient discharges through which of the following activities? 1. Decreasing the average length of stay of their clients 2. Confirming the integrity of the patient's support network 3. Reducing the per member per month medical costs of their clients 4. Confirming the adequacy of follow-up outpatient care A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Which of the following activities are not associated with a decrease in the legal liability associated with patient discharges? 1. Decreasing the average length of stay of their clients 2. Confirming the integrity of the patient's support network 3. Reducing the per member per month medical costs of their clients 4. Confirming the adequacy of follow-up outpatient care A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following activities are associated with a decrease in the legal liability associated with bad faith allegations? 1. Decreasing the average length of stay of their clients 2. Expediting claims adjudication 3. Reducing the per member per month medical costs of their clients 4. Securing an independent medical examination of the patient A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Which of the following activities are associated with an increase in the legal liability associated with bad faith allegations? 1. Decreasing the average length of stay of their clients 2. Unnecessarily delaying claims adjudication 3. Reducing the per member per month medical costs of their clients 4. Refusing an independent medical examination of the patient A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Malpractice is ___________________ that results in harm to another person. A) A professional's wrongful conduct B) A professional's failure to meet acceptable standards of care C) The improper discharge of a professional's duties D) All of the above E) None of the above ✔D Negligence is: A) An act of omission B) An act of commission C) Failing to use the degree of care a reasonably prudent and careful person would under similar circumstances D) None of the above C) 1, 2, 3 D) All of the above E) None of the above ✔D When distinguishing ethical from legal principles, which of the following statements are not considered to be true? 1. Civil punishments usually exist for lapses in legal duties. 2. Ethical duties usually exceed legal requirements. 3. Legal duties describe society's minimum acceptable behaviors. 4. Ethical obligations describe society's ideals for personal and professional behavior. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔E Which of the following statements (is)are true regarding ethical dilemmas? 1. It involves a decision between two or more possible outcomes. 2. It involves the breaking of an ethical principle. 3. The possible outcomes are in conflict. 4. Solving an ethical dilemma is usually illegal. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A In regard to ethical dilemmas, which of the following statements is(are) not true? 1. It involves a decision between two or more possible outcomes. 2. It involves the breaking of an ethical principle. 3. The possible outcomes are in conflict. 4. Solving an ethical dilemma is usually illegal. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Which of the following are ethical principles promulgated by the Case Management Society of America? 1. Autonomy 2. Beneficence 3. Nonmalfeasance 4. Justice A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D Which of the following attributes are not ethical principles promulgated by the Case Management Society of America? 1. Autonomy 2. Insouciance 3. Nonmalfeasance 4. Diversity A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B The ethical principle of justice implies all except which of the following qualities or attributes? 1. Upholding what is just or fair 2. Kindness 3. Equity of treatment 4. Charity A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B The ethical principle of beneficence implies all except which of the following qualities or attributes? 1. Upholding what is just or fair 2. Kindness 3. Equity of treatment 4. Charity A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A The ethical principle of autonomy is associated with all except which of the following attributes? 1. Promoting a patient's freedom to choose 2. Preventing harm to the patient 3. Encouraging patient self-advocacy 4. Encouraging patients to do what is right for the Case Manager A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B The ethical principle of nonmalfeasance is associated with all except which of the following attributes? 1. Promoting a patient's freedom to choose 2. Preventing harm to the patient 3. Encouraging patient self-advocacy 4. Encouraging patients to do what is right for the Case Manager A) 1, 3, 4 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A The ethical principle of veracity implies all except which of the following qualities or attributes? 1. Upholding what is just or fair 2. Adherence to the truth 3. Equity of treatment 4. Conforming in one's dealings with others to accuracy or precision A) 1, 3 B) 2, 4 C) 1, 2, 3 ✔D Which of the following activities is(are) associated with a decrease in legal liability associated with allegations of negligent patient assessment? 1. Understanding a patient's family and social support system 2. Understanding a patient's highest educational achievements 3. Understanding a patient's religious affiliations 4. Understanding a patient's cultural background A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D Which of the following activities is(are) associated with decreased risk of allegations of negligent referral? 1. Understanding the credentialing criteria of the provider network 2. Making a personal recommendation for a single provider 3. Providing patients with a list of providers, rather than the name of a single provider 4. Protecting a provider who provides irregular or suspicious medical treatments A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following activities is(are) associated with increased risk of allegations of negligent referral? 1. Understanding the credentialing criteria of the provider network 2. Making a personal recommendation for a single provider 3. Providing patients with a list of providers, rather than the name of a single provider 4. Protecting a provider who provides irregular or suspicious medical treatments A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B The legal definition of agency includes which of the following? 1. It is a relationship between two or more parties. 2. One party consents to act on the behalf of the other party. 3. The relationship carries the obligation that the principal is responsible for the actions of the agent. 4. The relationship carries no obligations for the agent to the principal. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔C Agents have which of the following legal obligations to their principals? 1. Using care and skill in the performance of their duties 2. Acting in good faith in the performance of their duties 3. Remaining within the limits of their authority 4. Advancing the interests of the agent A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔C Under the rules of agency, agents have which of the following legal obligations to their principals? 1. Using care and skill in the performance of their duties 2. Assuming new authority and exercising it in the interests of the principal 3. Acting in good faith in the performance of their duties 4. Advancing the interests of the agent A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Apparent authority (or ostensible agency) occurs with which of the following? 1. A principal has taken such actions that would indicate to third parties that someone is his or her agent. 2. A principal assigns duties and authorities to an agent via a written contract. 3. A principal, aware that a third party is acting as his or her agent, does nothing to stop it. 4. A principal assigns duties and authorities to an agent via an oral contract. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following pairs are examples of principals and their agents? 1. Hospitals and community physicians (not employed by hospital) 2. Hospitals and the nurses who work on the wards 3. Case Managers and patients 4. Insurers and Case Managers (employed by the insurer) A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Which of the following pairs are not examples of principals and their agents? 1. Hospitals and community physicians (not employed by hospital) 2. Hospitals and its phlebotomists (employed by the hospital) 3. Case Managers and network physicians 4. Insurers and their utilization review departments (employed by the insurer) A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following statements describes the legal term abandonment? 1. Termination of a professional relationship without reasonable notice to the patient 2. Termination of a professional relationship without payment of debts 3. Termination of a professional relationship without giving the patient an opportunity to acquire alternative care or services 4. Termination of a professional relationship because of a disagreement A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following statements does not describe the legal term abandonment? Which of the following statements best defines the legal term corporate negligence? A) A method of obtaining disclosure of information that is material and necessary to the underlying lawsuit by way of sworn oral testimony B) The ascertainment of what is not previously known; generally, the pretrial stage of a lawsuit beginning with the service of summons and complaint and concluding with the filing of a "note of issue" C) A pecuniary compensation recovered by the courts for acts of tort; these recoveries, or compensations, are for both tangible (medical expenses, lost earnings) and intangible (pain and suffering) injuries (torts) D) A legal doctrine that prohibits corporations from engaging in the practice of medicine, that is, the treatment of injuries, the discovery of the cause and nature of disease, and the administration of remedies or the prescribing of treatment E) A term that encompasses the legal grounds for managed care organizations' liability based on the corporate activities of the managed care organization itself, rather than on the care-related activities of participating healthcare professionals ✔E Which of the following statements best defines the legal term corporate practice of medicine? A) A method of obtaining disclosure of information that is material and necessary to the underlying lawsuit by way of sworn oral testimony B) The ascertainment of what is not previously known; generally, the pretrial stage of a lawsuit beginning with the service of summons and complaint and concluding with the filing of a "note of issue" C) A pecuniary compensation recovered by the courts for acts of tort; these recoveries, or compensations, are for both tangible (medical expenses, lost earnings) and intangible (pain and suffering) injuries (torts) D) A legal doctrine that prohibits corporations from engaging in the practice of medicine, that is, the treatment of injuries, the discovery of the cause and nature of disease, and the administration of remedies or the prescribing of treatment E) A term that encompasses the legal grounds for managed care organizations' liability based on the corporate activities of the managed care organization itself, rather than on the care-related activities of participating healthcare professionals ✔D Which of the following statements best defines the legal term damages? A) A method of obtaining disclosure of information that is material and necessary to the underlying lawsuit by way of sworn oral testimony B) The ascertainment of what is not previously known; generally, the pretrial stage of a lawsuit beginning with the service of summons and complaint and concluding with the filing of a "note of issue" C) A pecuniary compensation recovered by the courts for acts of tort; these recoveries, or compensations, are for both tangible (medical expenses, lost earnings) and intangible (pain and suffering) injuries (torts) D) A legal doctrine that prohibits corporations from engaging in the practice of medicine, that is, the treatment of injuries, the discovery of the cause and nature of disease, and the administration of remedies or the prescribing of treatment E) A term that encompasses the legal grounds for managed care organizations' liability based on the corporate activities of the managed care organization itself, rather than on the care-related activities of participating healthcare professionals ✔C Which of the following statements best defines the legal term discovery? A) A method of obtaining disclosure of information that is material and necessary to the underlying lawsuit by way of sworn oral testimony B) The ascertainment of what is not previously known; generally, the pretrial stage of a lawsuit beginning with the service of summons and complaint and concluding with the filing of a "note of issue' C) A pecuniary compensation recovered by the courts for acts of tort; these recoveries, or compensations, are for both tangible (medical expenses, lost earnings) and intangible (pain and suffering) injuries (torts) D) A legal doctrine that prohibits corporations from engaging in the practice of medicine, that is, the treatment of injuries, the discovery of the cause and nature of disease, and the administration of remedies or the prescribing of treatment E) A term that encompasses the legal grounds for managed care organizations' liability based on the corporate activities of the managed care organization itself, rather than on the care-related activities of participating healthcare professionals ✔B Which of the following statements best defines the legal term examination before trial? A) A method of obtaining disclosure of information that is material and necessary to the underlying lawsuit by way of sworn oral testimony B) The ascertainment of what is not previously known; generally, the pretrial stage of a lawsuit beginning with the service of summons and complaint and concluding with the filing of a "note of issue" C) A pecuniary compensation recovered by the courts for acts of tort; these recoveries, or compensations, are for both tangible (medical expenses, lost earnings) and intangible (pain and suffering) injuries (torts) D) A legal doctrine that prohibits corporations from engaging in the practice of medicine, that is, the treatment of injuries, the discovery of the cause and nature of disease, and the administration of remedies or the prescribing of treatment E) A term that encompasses the legal grounds for managed care organizations' liability based on the corporate activities of the managed care organization itself, rather than on the care-related activities of participating healthcare professionals ✔A Which of the following statements best defines the legal term joint and several liability? A) A debt, responsibility, or obligation B) An unwarranted appropriation or exploitation of another's private affairs with which the public has no legitimate concern; a wrongful intrusion into one's private activities in such a manner as to cause mental suffering, shame, or humiliation to a person of ordinary sensibilities C) A complication that is commonly associated with a procedure, but is not the result of negligence of the operator (physician, nurse, or other provider performing the procedure or treatment) D) A contractual arrangement between the insurer and the provider of service; is typically contained in a managed care contract. This provision specifies that the provider assumes the liability for covered services and cannot sue or assert any claims against enrollees for those covered services, even if the managed care organization becomes insolvent. E) An obligation of a group and its individual members. The party that has been harmed is able to sue all of the liable parties as a group, or any one of them individually. He or she may not, however, recover more compensation by suing each of them individually than by suing them as a group. ✔E Which of the following statements best defines the legal term hold harmless provision? A) A debt, responsibility, or obligation B) An unwarranted appropriation or exploitation of another's private affairs with which the public has no legitimate concern; a wrongful intrusion into one's private activities in such a manner as to cause mental suffering, shame, or humiliation to a person of ordinary sensibilities C) A complication that is commonly associated with a procedure, but is not the result of negligence of the operator (physician, nurse, or other provider performing the procedure or treatment) D) A contractual arrangement between the insurer and the provider of service; is typically contained in a managed care contract. This provision specifies that the provider assumes the liability for covered services and cannot sue or assert any claims against enrollees for those covered services, even if the managed care organization becomes insolvent. E) An obligation of a group and its individual members. The party that has been harmed is able to sue all of the liable parties as a group or any one of them individually. He or she may not, however, recover more compensation by suing each of them individually than by suing them as a group. ✔D Which of the following statements best defines the legal term inherent risk? A) A debt, responsibility, or obligation B) An unwarranted appropriation or exploitation of another's private affairs with which the public has no legitimate concern; a wrongful intrusion into one's private activities in such a manner as to cause mental suffering, shame, or humiliation to a person of ordinary sensibilities C) A complication that is commonly associated with a procedure, but is not the result of negligence of the operator (physician, nurse, or other provider performing the procedure or treatment) D) A contractual arrangement between the insurer and the provider of service; is typically contained in a managed care contract. This provision specifies that the provider assumes the liability for covered services and cannot sue or assert any A failure to use such care in making a referral, as a reasonable professional would use under similar circumstances; referring a patient to a provider who does not possess the skills, experience, licensure, or certifications to care for that patient A failure to use the degree of care a reasonably prudent and careful person would use under similar circumstances A contractual arrangement between a purchaser and provider; in this arrangement, the provider is obligated to render products or services to the purchaser at the same rate as his or her most favored customer Bound by law or fairness; responsible; accountable ✔D Which of the following statements best defines the legal term negligence? A) A failure on the part of the managed care organization to exercise reasonable care in screening and selecting providers B) A failure to use such care in making a referral, as a reasonable professional would use under similar circumstances; referring a patient to a provider who does not possess the skills, experience, licensure, or certifications to care for that patient C) A failure to use the degree of care a reasonably prudent and careful person would use under similar circumstances D) A contractual arrangement between a purchaser and provider; in this arrangement, the provider is obligated to render products or services to the purchaser at the same rate as his or her most favored customer E) Bound by law or fairness; responsible; accountable ✔C Which of the following statements best defines the legal term negligent referral? A) A failure on the part of the managed care organization to exercise reasonable care in screening and selecting providers B) A failure to use such care in making a referral, as a reasonable professional would use under similar circumstances; referring a patient to a provider who does not possess the skills, experience, licensure, or certifications to care for that patient C) A failure to use the degree of care a reasonably prudent and careful person would use under similar circumstances D) A contractual arrangement between a purchaser and provider; in this arrangement, the provider is obligated to render products or services to the purchaser at the same rate as his or her most favored customer E) Bound by law or fairness; responsible; accountable ✔B Which of the following statements best defines the legal term negligent referral? A) A failure on the part of the managed care organization to exercise reasonable care in screening and selecting providers B) A failure to use such care in making a referral, as a reasonable professional would use under similar circumstances; referring a patient to a provider who does not possess the skills, experience, licensure, or certifications to care for that patient C) A failure to use the degree of care a reasonably prudent and careful person would use under similar circumstances D) A contractual arrangement between a purchaser and provider; in this arrangement, the provider is obligated to render products or services to the purchaser at the same rate as his or her most favored customer E) Bound by law or fairness; responsible; accountable ✔B Which of the following statements best defines the legal term negligent credentialing? A) A failure on the part of the managed care organization to exercise reasonable care in screening and selecting providers B) A failure to use such care in making a referral, as a reasonable professional would use under similar circumstances; referring a patient to a provider who does not possess the skills, experience, licensure, or certifications to care for that patient C) A failure to use the degree of care a reasonably prudent and careful person would use under similar circumstances D) A contractual arrangement between a purchaser and provider; in this arrangement, the provider is obligated to render products or services to the purchaser at the same rate as his or her most favored customer E) Bound by law or fairness; responsible; accountable ✔A Which of the following components are necessary to constitute a malpractice incident? 1. A deviation from the approved and accepted standards of care 2. A violation of federal law 3. An injury to the patient that resulted from negligence 4. A violation of criminal law A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following components are not necessary to constitute a malpractice incident? 1. A deviation from the approved and accepted standards of care 2. A violation of federal law 3. An injury to the patient that resulted from negligence 4. A violation of criminal law A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Which of the following statements best describes the legal term ombudsman? A) A person whose occupation consists of investigating customer complaints against his or her employer B) An agreement between two litigants to settle the contested matter privately, without being referred to the judge for authorization or approval, before the Court has rendered its decision C) The quality or condition of being secluded from the presence or view of others; the state of being free from unsanctioned intrusion D) Information that a person authorized to practice medicine, nursing, counseling, and so on, acquires in attending to a patient in a professional capacity, and that is necessary to enable him or her to act in that capacity E) A doctrine of law in which mere proof that an occurrence took place is sufficient under the circumstances to shift the burden of proof upon the defendant to prove that it was not due to his or her negligence ✔A Which of the following statements best describes the legal expression out of court settlement? A) A person whose occupation consists of investigating customer complaints against his or her employer B) An agreement between two litigants to settle the contested matter privately, without being referred to the judge for authorization or approval, before the Court has rendered its decision C) The quality or condition of being secluded from the presence or view of others; the state of being free from unsanctioned intrusion D) Information that a person authorized to practice medicine, nursing, counseling, and so on, acquires in attending to a patient in a professional capacity, and that is necessary to enable him or her to act in that capacity E) A doctrine of law in which mere proof that an occurrence took place is sufficient under the circumstances to shift the burden of proof upon the defendant to prove that it was not due to his or her negligence ✔B Which of the following statements best describes the legal term privacy? A) A person whose occupation consists of investigating customer complaints against his or her employer B) An agreement between two litigants to settle the contested matter privately, without being referred to the judge for authorization or approval, before the Court has rendered its decision C) The quality or condition of being secluded from the presence or view of others; the state of being free from unsanctioned intrusion D) Information that a person authorized to practice medicine, nursing, counseling, and so on, acquires in attending to a patient in a professional capacity, and which is necessary to enable him or her to act in that capacity D) A document issued by the plaintiff's attorney, which when properly delivered, commences a legal action E) The legal liability that a person may have for the actions of someone else ✔A Which of the following statements best describes the legal expression summons? A) This maxim means that a master is liable, in certain cases, for the wrongful acts of his or her servant (and a principal for those of his or her agent). A master/servant or principal/agent relationship exists in which one person, for pay or other valuable consideration, enters into the service of another and devotes his or her personal labor for an agreed period. B) The period of time in which a plaintiff may bring lawsuit after an incident has occurred C) A judicial process requiring a witness to give relevant information or testimony "under penalty" of contempt for disobedience D) A document issued by the plaintiff's attorney, which when properly delivered, commences a legal action E) The legal liability that a person may have for the actions of someone else ✔D Which of the following statements best describes the legal expression vicarious liability? A) This maxim means that a master is liable, in certain cases, for the wrongful acts of his or her servant (and a principal for those of his or her agent). A master/servant or principal/agent relationship exists in which one person, for pay or other valuable consideration, enters into the service of another and devotes his or her personal labor for an agreed period B) The period of time in which a plaintiff may bring lawsuit after an incident has occurred C) A judicial process requiring a witness to give relevant information or testimony "under penalty" of contempt for disobedience D) A document issued by the plaintiff's attorney, which when properly delivered, commences a legal action E) The legal liability that a person may have for the actions of someone else ✔E Which of the following statements is(are) true regarding the legal term respondeat superior? 1. It translates as "Let the master answer." 2. It proves negligence on the part of the defendant. 3. It holds that in certain circumstances, the employer is responsible for wrongful acts committed by the employee. 4. It translates as "The thing speaks for itself."" A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following statements is(are) not true regarding the legal term respondeat superior? 1. It translates as "Let the master answer." 2. It proves negligence on the part of the defendant. 3. It holds that in certain circumstances, the employer is responsible for wrongful acts committed by the employee. 4. It translates as "The thing speaks for itself." A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Which of the following statements is(are) true regarding the legal term tort? 1. It comes from a Latin word that means "twist." 2. It implies that testimony has been given falsely. 3. It refers to damage or injury that is done willfully or negligently. 4. It refers only to medical malpractice cases. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following statements is(are) not true regarding the legal term tort? 1. It comes from a Latin word that means "twist." 2. It implies that testimony has been given falsely. 3. It refers to damage or injury that is done willfully or negligently. 4. It refers only to medical malpractice cases. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B A request by an insured or a provider to re-review a denial of a utilization review organization's decision is also known as: 1. An appeal 2. A reconsideration 3. An expedited appeal 4. An IME A) 1, 2 B) 1, 3 C) 1, 4 D) All of the above E) None of the above ✔A As a result of the case of Wickline v. the State of California, which of the following is true? 1. Providers can be held accountable for negative outcomes when they discharge patients solely at the request of the insurer or payer. 2. Case Managers can be held liable for negative outcomes as a consequence of their denials. 3. Insurers or utilization review firms can be held liable for negative outcomes as a consequence of their denials. 4. If a provider appeals an adverse determination and a negative outcome occurs, the liability may be passed to the insurer. A) 1, 2, 3 B) 2, 3, 4 C) All of the above D) None of the above ✔C During a case management interview, in a workers' compensation case, the patient confides to the Case Manager that he is a recovering alcoholic and has been alcohol free for 5 years. The Case Manager should: A) Include the information in the psychosocial section of his or her insurance company report. B) Immediately notify the patient's attending physician. C) Make no comment verbally or in writing as it has no current bearing on a work- related injury. D) Close the case. ✔C ______________________ refers to the Case Manager having a duty to promote good and to be the patient's advocate. A) Nonmaleficence B) Beneficence C) Advocacy 2. "Your last physical therapy report states you have increased your strength and flexibility."" 3. "Other patients with this injury returned to work 2 weeks ago." A) 1, 2 B) 2, 3 C) 2 D) All of the above E) None of the above ✔C The Case Manager knows that adaptive equipment along with instruction and training in its use results in: A) Enhanced self-esteem B) Independence C) Decreased reliance on home health aides and others to perform ADLs D) All of the above E) None of the above ✔D Which of the following statements is(are) true regarding the clinical consequences of head injuries? 1. Patients may become depressed. 2. A patient's cognitive ability may be impaired. 3. Emotional lability is common. 4. Chronic headaches may result. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) 1, 2, 4 E) None of the above ✔D Which of the following statements is(are) true regarding the clinical consequences of head injuries? 1. Patients may become depressed. 2. A patient's cognitive ability may improve as a result. 3. Chronic headaches may result. 4. Emotional stability is common. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following statements is(are) not true regarding the clinical consequences of head injuries? 1. Patients may become depressed. 2. A patient's cognitive ability may improve as a result. 3. Chronic headaches may result. 4. Emotional lability is common. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B When the Case Manager is planning for timely rehabilitation, she or he must do which of the following in order to provide for the coordination of the medical care the patient requires? A) Arrange for an objective second opinion. B) Request the diagnostic films for the medical director to read. C) Do an on-site evaluation. D) Develop and clarify the medical care plan of the attending physician. ✔D A patient has just had a full diagnostic work up of his condition. The need for surgery has been ruled out, and the condition has been diagnosed as chronic. Which of the following is(are) true of the patient's follow-up needs? A) The patient should be followed every 2 months by the surgeon, in case his or her condition changes and he or she requires surgery. B) Several other opinions should be sought to confirm the first diagnosis. C) Follow-up with the patient's primary care physician is indicated to obtain any needed treatment, monitoring, or medications required for the chronic condition. D) All of the above E) None of the above ✔C Patients with chronic back pain require: A) Supportive conservative treatment B) Whatever the patient and his or her various treating physicians determine is helpful C) Chiropractic care 3 times a week for life D) Continual testing to monitor the condition ✔A Dual relationships refers to: A) The relationship between the Case Manager and the physician B) The relationship in which the Case Manager has more than one role in respect to a patient, subordinate, or student C) The relationship between the Case Manager and the patient and his or her family D) None of the above ✔B The court case of Wickline v. State of California found: 1. Medical doctors have a duty to protest adverse determinations by payers. 2. Medical doctors can shift their liability to payers if they do protest adverse determinations. 3. Case Managers are not liable for their roles in adverse determinations. 4. Payers of heath care can be held accountable, if their adverse decisions are arbitrary, for cost containment, and are not based on acceptable medical standards of practice in the community. A) 1, 2, 3 B) 2, 3, 4 C) 1, 2, 4 D) None of the above ✔C In a malpractice suit, the plaintiff must prove two points: 1. His compliance with the prescribed treatment plan 2. Negligence on the part of the Case Manager 3. Injury from the Case Manager's negligence 4. Intent on the part of the Case Manager A) 1, 4 B) 2, 3 C) None of the above D) All of the above ✔B The Case Manager can reduce his or her potential for liability by: 1. Purchasing case management liability insurance 2. Keeping the lines of communication open between the patient, family, provider, and him- or herself 3. Educating the patient and family, and testing for understanding 4. Empowering the patient to participate in planning his or her care 5. Documenting all discussions with the patient, family, and his caregivers A) 1, 2, 3, 4 B) 2, 3, 4, 5 C) All of the above D) None of the above ✔B Which of the following statements is(are) not true regarding the psychological aspects of catastrophic illness or injury? 1. Certain illnesses have the same or similar effects on all patients. 2. Minor illnesses may cause catastrophic physiological reactions in some patients. 3. Major illnesses and grave prognoses will cause depression in all patients. 4. A patient's reactions to illness may extend beyond the illnesses' pain and disability and can affect the patient's self-respect and social status. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following reactions do patients with major illness or injury commonly experience? 1. Loss 2. Anger 3. Fear and anxiety 4. Depression A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D Which of the following reactions do patients with major illness or injury commonly experience? 1. Loss 2. Euphoria 3. Fear and anxiety 4. Contentment A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following reactions do patients with major illness or injury not experience? 1. Loss 2. Happiness 3. Fear and anxiety 4. Peace A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Which of the following statements is(are) true regarding how Case Managers deal with patients with catastrophic illnesses and injury? 1. Anxiety may be treated with education and counseling. 2. Severe depression may respond to appropriate antidepressant medication and should be recommended. 3. Diagnosing depression may require skillful interviewing. 4. Case Managers should avoid dealing with the psychological aspects of major illnesses. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔C Which of the following statements is(are) true regarding how Case Managers deal with patients with catastrophic illnesses and injury? 1. Anxiety may be treated with education and counseling. 2. Severe depression will never respond to antidepressant medication. 3. Diagnosing depression may require skillful interviewing. 4. Case Managers should avoid dealing with the psychological aspects of major illnesses. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following statements is(are) not true regarding how Case Managers deal with patients with catastrophic illnesses and injury? 1. Anxiety may be treated with education and counseling. 2. Severe depression responds only to electroconvulsive therapy, and it should be recommended. 3. Diagnosing depression may require skillful interviewing. 4. Case Managers should avoid dealing with the psychological aspects of major illnesses. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Which of the following statements is(are) true regarding patients with catastrophic injuries and illnesses? 1. The negative effects are felt only by the patient. 2. The spouse is never affected by the patient's injury. 3. The Case Manager should restrict his or her inquiries to the patient's reactions, mood, and coping abilities. 4. A history of adequately coping with major illness is a negative predictor for a patient's future coping ability. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔E Which of the following statements is(are) true regarding patients with catastrophic injuries and illnesses? 1. The negative effects are felt by the patient and his or her family, friends, and coworkers, among others. 2. The spouse is never affected by the patient's injury. 3. The Case Manager should expand his or her inquiries beyond the patient's reactions, mood, and coping abilities to those of the family, friends, and caretakers. 4. A history of adequately coping with major illness is a negative predictor for a patient's future coping ability. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following statements is(are) not true regarding patients with catastrophic injuries and illnesses? A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above Which of the following characteristics is(are) not common to the adaptable family? 1. The family is inflexible in its role relationships. 2. The family maintains its ability to solve problems within the family. 3. The family communicates poorly with each other and outsiders. 4. The family seeks and accepts help willingly. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following spiritual questions might a patient with a catastrophic illness ask him- or herself? 1. Has my life had meaning? 2. Why is this happening to me? 3. What is the purpose of my life? 4. Is this a punishment from God? A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔D Which of the following spiritual questions might a patient with a catastrophic illness ask him- or herself? 1. Has my life had meaning? 2. How much will my care cost? 3. What is the purpose of my life? 4. Will I be entitled to disability? A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following is(are) true regarding spirituality in patients suffering severe illness or disability? 1. Spiritual concerns are rarely important to these patients. 2. Spiritual concerns are regularly addressed by doctors and nurses caring for them. 3. These patients are always receptive to religious prosthelitizing. 4. Spiritual concerns are the same as religious concerns. A) 1, 3 B) 2, 4 C) 1, 2, & 3 D) All of the above E) None of the above ✔E Which of the following is(are) true regarding spirituality in patients suffering severe illness or disability? 1. Spiritual concerns are commonly important to these patients. 2. Spiritual concerns are rarely addressed by doctors and nurses caring for them. 3. These patients are rarely receptive to religious prosthelitizing. 4. Spiritual concerns are the same as religious concerns. A) 1, 3 B) 2, 4 C) 1, 2, & 3 D) All of the above E) None of the above ✔C Ethical boundaries on spiritual discussion include all of the following except: 1. Avoid being judgmental of clinical decisions based on spiritual beliefs. 2. Religious prosthelitizing is appropriate for a case manager in this setting. 3. Case Managers should avoid spiritual counseling while acting as a patient's case manager. 4. Praying with his or her patient is always appropriate for a Case Manager. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔B Ethical boundaries on spiritual discussion include all of the following except: 1. Being judgmental of clinical decisions based on spiritual beliefs is appropriate in that it may encourage the patient to make a better clinical decision. 2. Religious prosthelitizing is inappropriate for a Case Manager in this setting. 3. Case managers should provide spiritual counseling while acting as a patient's Case Manager. 4. Praying with his or her patient is appropriate for a Case Manager only under limited conditions. A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A It is appropriate for a Case Manager to pray with her or his patients under which of the following conditions? 1. When the patient initiates the request 2. After an appropriate referral to a chaplain or spiritual counselor has been made 3. When a chaplain or spiritual counselor is not available 4. Only when the Case Manager is also a trained religious or spiritual counselor A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔C It is inappropriate for a Case Manager to pray with her or his patients under which of the following conditions? 1. When the Case Manager initiates the request 2. After an appropriate referral to a chaplain or spiritual counselor has been made 3. When a chaplain or spiritual counselor is not available 4. Only when the Case Manager is also a trained religious or spiritual counselor A) 1, 3 B) 2, 4 C) 1, 2, 3 D) All of the above E) None of the above ✔A Which of the following statements is(are) true regarding a spiritual history? 1. Patients are rarely interested in discussing their spiritual issues, so a spiritual history is always inappropriate. 2. It is an exploration in the meaning and purpose of a patient's life. 3. It should be administered only by a trained religious or spiritual counselor. 4. It addresses a patient's specific preferences or needs regarding medical care, death, and dying that are based on his or her religious beliefs. A) 1, 3