CCM Healthcare Regulations and Compliance 2

Question 1

Under EMTALA, a hospital with an emergency department must provide a medical screening examination to any individual who presents and requests examination. Who is responsible for conducting this screening?

Accepted Answer

A qualified medical person as defined by the hospital's bylaws

Answer

EMTALA requires a medical screening examination by a qualified medical person, which the hospital defines in its bylaws and may include non-physician practitioners.

Question 2

The Stark Law (Physician Self-Referral Law) prohibits physicians from referring Medicare patients to entities for designated health services if the physician has a financial relationship with that entity. Which of the following is a designated health service under Stark?

Accepted Answer

Physical therapy services

Answer

Physical therapy is explicitly listed as a designated health service under the Stark Law, making self-referrals to PT entities with financial relationships prohibited.

Question 3

A case manager discovers that a patient's insurer denied a claim citing lack of medical necessity. Under which federal law does the patient have the right to an internal appeal followed by an external independent review?

Accepted Answer

ACA (Affordable Care Act)

Answer

The ACA established the right to an internal appeal and external independent review for non-grandfathered health plans when claims are denied for lack of medical necessity.

Question 4

Which CMS condition of participation requires hospitals to have a utilization review committee that evaluates the medical necessity of admissions?

Accepted Answer

Conditions of Participation (CoP) – Utilization Review

Answer

CMS Conditions of Participation for hospitals include a Utilization Review standard requiring a committee to review admissions and continued stays for medical necessity.

Question 5

A case manager working in a skilled nursing facility must ensure the facility complies with the Minimum Data Set (MDS) requirements. What is the primary regulatory purpose of the MDS?

Accepted Answer

To assess residents and drive care planning and reimbursement under Medicare

Answer

The MDS is a federally mandated comprehensive assessment tool used in SNFs to guide care planning and determine Medicare payment under the Patient-Driven Payment Model.

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Practice Test

CCM Healthcare Regulations and Compliance 2