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CERTIFIED CASE MANAGER exam questions
with solved solutions
Who is eligible for WIC? - ANSWER>>Women, infants, children
What does WIC provide? - ANSWER>>Vouchers for food, infant cereal, baby food,veggies, etc
Utilization Review - ANSWER>>Evaluates appropriateness of an admission to a health care facility or extension of stay; also measures efficiency
What is the CAGE acronym stand for and when is it used? - ANSWER>>Screens for alcoholism
- Have you felt the need to CUT down on drinking?
- Have ppl ANNOYED you by criticizing your drinking?
- Have you felt GUILTY about drinking?
- Have you felt the need for a drink in the AM (EYE Opener)
Who does hospice serve? - ANSWER>>Both patient and family
What is the Medicare criteria for hospice and which Part covers it? What will Medicare NOT cover? - ANSWER>><6 month life expectancy -Part A -Not cover treatment to cure illness, room and board $0 OOP cost for hospice
What is the O2 sat level for Medicare to approve home O2? - ANSWER>>88% or less to approve home O2 at rest/awake 88% or less x5 min while asleep
custodial care - ANSWER>>Bathing, eating, dressing
Family typically covers it
SSDI (Social Security Disability Income) - ANSWER>>Means of income for an individual who are restricted in their ability to work due to a disability (usually physical); total disability (not short term);available to workers who have accumulated a sufficient number of work credits -must be younger than 65 -5 month waiting period -SSDI is funded by the Social Security taxes paid by workers, employers and self- employed people
POS (Point of Service) - ANSWER>>Allows individual to choose provider Higher cost in premiums, deductibles and coinsurance
Primary HIV infection prevention - ANSWER>>reduction of transmission and acquisition of HIV
secondary HIV infection prevention - ANSWER>>prevent a person with HIV from becoming ill or dying
What does the Rancho Los Amigos scale measure? - ANSWER>>Assess individuals after a closed head injury, such as traumatic brain injury (TBI), based on cognitive and behavioural presentations as they emerge from COMA I = no response to all stimuli III = localized response (specific not inconsistent) V = confused/inappropriate VIII = purposeful, appropriate, A&O x
Delerium - ANSWER>>- Disturbance of conciousness; reduced ability to focus, sustain or shift attention; change in cognition
- Develops over hours or days and fluctuates during the course of the day
due diligence - ANSWER>>Effort made by someone to avoid harming himself or someone else
**What is the main difference between clinical vs ethical committees? - ANSWER>>Types of experts
Clinical = experts in clinical issues Organizational= utilization management, code of professional conduct, corporate compliance
How often should CM send a cost benefit analysis of their case load to their employer? - ANSWER>>Quarterly
What is Worker's Comp and how is it paid? If a person accepts Worker's Comp, what can they NOT expect? - ANSWER>>- Provides coverage or injury or illness at work or that's work related -premiums are paid by employer -if worker is covered by and accepts coverage under worker's comp, they may NOT claim benefits under a group insurance policy or bring suit against employer for work related injuries
What does OASIS stand for and who receives reimbursement through OASIS? - ANSWER>>Outcome and Assessment Information Set Any home health agency MUST use this form to get reimbursement through Medicare
What is the purpose for pharmacy benefit management (PBM)? - ANSWER>>They are 3rd party administrators of Rx drug programs. They are responsible for processing and paying Rx claims and develop formularies. They help contain Rx cost through generic and lower tier Rx
What is HEDIS? - ANSWER>>Health Plan Employer Data and Info Set -Performance measurement for managed care
-Focus on QUALITY of system, PROCESS, SERVICES, and ACCESS to services (Effectiveness of care) -Developed by NCQA (Nat'l Committee for Quality Assurance) -Data is available to consumers and providers
Prospective Payment System (PPS) - ANSWER>>System of payment which health care services (eg. SNF, hospital) get reimbursed through per-determined reimbursement rates based on Dx at time of admission
How is reimbursement in the following PPS categories? Inpatient Ambulatory Rehab SNF HHC - ANSWER>>Inpatient = DRG Ambulatory = APC (ambulatory payment classification) Rehab = CMG (case mix group) SNF = RUG (resource utilization group) HHC = HHRG (home health resource group)
What is the reimbursement process for PPOs? - ANSWER>>Reimbursed through DRG (diagnosis related groups)
What are DRGs? - ANSWER>>Rates of reimbursement for particular categories of services DRGs are a means of classifying a patient under a particular group where those assigned are likely to need a similar level of hospital resources for their care. This allows hospital administrators to more accurately determine the type of resources needed to treat a particular group and to predict more closely, the cost of that treatment
What is Continuous Quality Improvement (CQI)? - ANSWER>>ongoing process that involves identification, description, and analysis for areas of improvement,
Life planner - ANSWER>>Develops a Life care plan; Help pts who have suffered catastrophic injuries and illnesses, advocate for them, and plan out their care Part of a legal team in medical malpractice/personal injury case; also active in worker's comp Can be RN, rhab RN, SW, PT, etc
life plan - ANSWER>>A document based on EBP and assessment/research; provides a plan for furture and current needs with associated costs for pts with catastrophic injury or chronic illness
CARF (commision on accreditation of rehab facilities) - ANSWER>>Private, nonprofit organization that establishes standards of quality of services to ppl w/disabilities Offers voluntary accreditation for rehab facilities and et of nat'lly recognized standards
Medicare Part A - ANSWER>>Hospitalization
Medicare Part C - ANSWER>>Offered by private insurers, "Medicare Advantage" plans
Medicare Part B - ANSWER>>Voluntary Program, covers outpatient services, physician services, ER visits
Medicare Part D - ANSWER>>Rx coverage
Examples of employers that are exempt from the ADA - ANSWER>>Employers with fewer than 15 employees, federal gov't, Native American tribes, religious or private membership organizations
When is a life plan used? - ANSWER>>In a court system as groundwork for settlement of a claim for personal injury or medical liability
National Committee on Quality Assurance (NCQA) - ANSWER>>Evaluates quality of care provided by healthcare organizations and managed care organizations; they set predetermined standards of care
5 ETHICAL principles of CM - ANSWER>>1. Beneficence (do good)
- Non malfeasance (do no harm)
- Veracity (truth, honesty)
- Justice (equality of treatment)
- Pt autonomy (freedom to choose)
tort - ANSWER>>Injury, damage or wrongful act done WILLFULLY or negligently
What are 3 common dilemmas of CM? - ANSWER>>1. Focus of advocacy (CM conflict between best interest of pt, pt fam, payer and society)
- Supremacy of values (clash of values of CM, CM employer, pt, family or insurer)
- Conflict of Duties (carry out wishes of client may cause harm to others--ex: HIV+ pt confidentiality to others)
Important points for release of AIDS/HIV info - ANSWER>>-Varies by state -Each state requires a signed form -if written permission is NOT obtained in states w/requirements for a form, ALL references to HIV status must be deleted, including test, and the results
When can client confidentiality be broken? - ANSWER>>1. Intent to harm
- Emergency services
- Protect from self harm
- Notify authorities of abuse, neglect
- Mandated reporting by public health laws
- Court order/subpoena
- Payment for services
- Professional consultation
-Typical reimbursement by HMO -Whether mbr uses services once or more, provider receives the same payment
What is the transition care process? - ANSWER>>-Moving patient from highly complex to less complex care setting -Ensure appropriate resources and services are provided to patients in appropriate setting or level of care
What is subacute (how is it different from a SNF)? - ANSWER>>-inpatient care who has an ACUTE illness -goal oriented tx given immediately after or instead of hospitalization
What is a SNF (how is it different from a subacute)? - ANSWER>>residents who require nursing care or rehab (chronic conditions)
work conditioning program - ANSWER>>Individualized, work oriented program designed to restore client's STRENGTH and ENDURANCE so they can return to work (usually under OT or PT care) 2-4 hours/day for 2-4 wks
work hardening program - ANSWER>>Interdisciplinary, job specific program (functional job aspects) of activity w/the goal of returning to work; much more aggressive; stimulate work activities 3-4 hours+/day, 3-5 days a week
eligibility requirements for Medicare - ANSWER>>65 y/o eligible for SSDI Disables once they are on SSDI for 24 months ESRD or on dialysis or requires transplant
transitional hospitals - ANSWER>>acute care facilities for pts medically stable and rehab is too complex for SNF or ECF (ex: burn, HD, TPN, vents)
NOT considered a pre-existing condition - ANSWER>>pregnancy, newborn, adopted children under 18, children placed for adoption who have been covered under the health plan for at least 30 days
goal of disease management - ANSWER>>Reach individuals at the EARLIEST possible time in the disease cycle
coordination of benefits (COB) - ANSWER>>-Prevents double payment for services when person has coverage from 2 or more sources -agreement that uses language created by the Nat'l Assoc. of Insurance Commissioners
transfer penalty - ANSWER>>period of time when enrollee is not eligible for medicaid
What is triggering algorithm and who uses it? - ANSWER>>Used by CM to determine who might benefit from CM services
American Hospital Association Bill of Rights - ANSWER>>-pts have access to an interpreter
vocational rehab - ANSWER>>Process that enables people w/functional, psych, cognitive, emotional impairment or health condition to OVERCOME BARRIES to accessing, maintaining or returing to employment -Separate from workers comp -can provide independent living skills,
Can an employer require a medical exam or ask questions about a disability? - ANSWER>>-During an application, an employer CANNOT ask if you are disabiled or the severity of disability -They CAN ask how you perform a job -CANNOT require a medical exam before a job offer
successful negotiation factors - ANSWER>>trust, information, focus on pt, respect, timely communication, active listening
distributive justice - ANSWER>>Moral basis for dissemination of goods and evils, burden/benefits, especially when making decisions regarding allocation of health care resources
How long do symptoms of major depression for diagnosis have to be present? - ANSWER>>Depressed mood or loss of interest for at least 2 weeks
What is the expected outcome of workman's comp? - ANSWER>>Facilitate the eventual return of injured worker to gainful employment
viatical settlement - ANSWER>>Selling of one's life in insurance policy to a 3rd party before one's death. Policy holder benefits rather than beneficiaries. Usually sold 40-90% face value depending on life expectancy (< time = > $)
reasonable accommodation - ANSWER>>Any change in work environment or in the way a job is performed that enables a person w/disability to enjoy equal employment -Employer except if cost causes undue hardships
ombudsman - ANSWER>>Mediator Person assigned that mediates fair settlements especially between aggrieved parties
Emergency Medical Treatment & Labor Act (EMTALA) - ANSWER>>"Anti Dumping Law" Federal law requires any pt that comes to the ED is to be stabilized and treated regardless of insurance status or ability to pay
Reverse Mortgage - ANSWER>>Converts part of equality in their home for cash Lender makes payment to borrower
Borrower not required to pay back loan until sold or vacated Borrower still pays utilities and taxes for 62 y/o +
Difference between Disability vs Impairment vs Handicap - ANSWER>>Disability- restriction or lack of ability to PERFORM an ACTIVITY in the manner/WNL for a human (ex: for CP, inability to walk)
Handicap - ANSWER>>Handicap-DISADVANTAGE given to an individual that limits or prevents fulfillment of a ROLE that is normal (ex: CP prevents person from fulfilling normal role at home, like sports activities his age considered normal)
Impairment - ANSWER>>loss, abnormality of psychological, physical STRUCTURE or Function (ex: CP, inability to move legs easily at joints)
methadone - ANSWER>>heroin or morphine like drugs; also also be given for meth addicts
barbiturates - ANSWER>>Cause CNS depression Used as sedatives, anxiolytics, anticonvulsants and tx insomnia
What are the 3 areas to determine functional status of a patient? - ANSWER>>1. ADLS (dress, bathe, feed, toilet)
- IADLS (shopping, prep meals, house work)
- Environmental factors or barriers (stairs, w/c)
functional capacity exam - ANSWER>>Assess physical and functional ABILITY to perform a task
Types of Advance directives - ANSWER>>Living Will - spells out tx you would/wouldn't use to keep you alive DPOA (aka Health care proxy)- name person to make decisions for you when you've been unable to do so
For Worker's comp, what is allowed regarding changing MDs? - ANSWER>>The injured worker may change provider once without insurer approval and with insurer approval afterward
What are the 6 steps of fitting a trans tibial BKA prosthesis? - ANSWER>>1. Cast of stump = push on soft prominences and avoid bone ones
- Model of boney prominence so weight will be transferred
- Interface - prosthesis that touches residual limb
- Alignment of prosthesis
- Definitive prosthesis = fully functional within 1 year of amputation
- Repair and replacement and adjustment maintenance
medigap - ANSWER>>Private insurance which helps pay gaps in medicare (co insurance, deductables, rx)
medi-select - ANSWER>>HMO Specifies hospitals, sometimes PCP, cheaper premiums than medigap
preferred provider organizations (PPO) - ANSWER>>large group of medical providers negotiated discounted fee-for-service schedule
exclusive provider organizations (EPO) - ANSWER>>network of contracted physicians care for enrollees at a discounted rate
What are the 8 steps of managing patient care? - ANSWER>>1. Referral (Dx, driven, repeat services)
- Assessment - info triggered regerral
- Planning - contact client health care provider
- Reporting - progress, desired outcome
- Obtain approval - doc. signed by client
- Coordination
- F/U Monitoring
- Evaluation
What are the 8 initial assessment categories for CM of the client? - ANSWER>>1. Cognitive fxn
- Dx/Med hx
- Rx
- Care access - eval of services
- Fxn status (ALDS, IADLS)
- Social situtation
- Nutrition
- Emotional status
MDS (minimum data set) - ANSWER>>assessment tool used in SNF to determine clinical needs of residents -place them in a resource utilization group (RUG)
RUG (resource utilization group) - ANSWER>>Determines reimbursement rate from medicare in a SNF
root cause analysis (RCA) - ANSWER>>a collective term that describes a wide range of approaches to uncover causes of problems--the HIGHEST-LEVEL cause of a problem
root cause - ANSWER>>a factor that caused a non conformance and permanently eliminated through process improvement
What is TEFRA (tax equality and fiscal responsibility action of 1982)? - ANSWER>>1. It created DRG (diagnosis related group)--cost of care for dx
applied companies with how many employees? - ANSWER>>company w/ 20+ employees (applies to 40 yo+)
ERISA- Employee Retirement Income Security Act applied companies with how many employees? - ANSWER>>(pension plan) 100+ employees
FMLA applied companies with how many employees? - ANSWER>>50+ employees
COBRA applied companies with how many employees? - ANSWER>>20+ employees
Longshore and Harbor Workers' Compensation Act (LHWCA) - ANSWER>>compensation and medical care to employees disabled from injuries that occur on the navigable waters of the United States or in adjoining areas used in loading, unloading, repairing or building a vessel. Survivor benefits also are provided if injury causes includes workers employed in maritime occupations
The Federal Employees' Compensation Act - ANSWER>>The United States shall pay compensation coverage to three million Federal and Postal workers including wage replacement, medical rehabilitation benefits for work-related injury and occupational disease. FECA is a highly cost-effective self-insurance system.
Railroad Workers Act - ANSWER>>The RLA was the first federal law guaranteeing the right of workers to organize and join unions and elect representatives without employer coercion or interference. applies to freight and commuter railroads, airlines, companies directly or indirectly controlled by carriers who perform services related to transportation
CHIP Children's Health Insurance Program - ANSWER>>serves uninsured children up to age 19 in families with incomes too high to qualify them for Medicaid. States have
broad discretion in setting their income eligibility standards, and eligibility varies across states
Medicaid - ANSWER>>health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.
Title XIX of the Social Security Act - ANSWER>>Medicaid was signed into law in 1965 along side Medicare
Retiree insurance with medicare - ANSWER>>if you're retired and have Medicare and group health plan (retiree) coverage from a former employer, generally, Medicare pays FIRST (primary) for your health care bills and your group health plan coverage pays second
Medicare Advantage plan - ANSWER>>variety of private health plans — most often HMOs and PPOs — that Medicare offers as a coverage alternative to the traditional program (Medicare Parts a & B). Most charge a monthly premium in addition to the Part B premium. All plans, by law, have annual limits on out-of- pocket costs
Black Lung Benefits Act - ANSWER>>provides monthly payments and medical benefits to coal miners totally disabled from pneumoconiosis (black lung disease) arising from employment in or around the nation's coal mines.
3 Types of O2 delivery devices - ANSWER>>Gas, liquid or oxygen conentrator
Gas oxygen - ANSWER>>The gas form of oxygen is put into variously sized cylinders or tanks. The cylinders or oxygen tanks contain compressed oxygen. The cylinder is equipped with a regulator that controls the flow rate. Because the flow of oxygen out of the cylinder is constant, an oxygen conserving device may be
