CCM Healthcare Regulations and Compliance 4 — Questions and Answers
Question 1: A case manager working for a managed care organization must understand the False Claims Act (FCA). Under the FCA, what is the minimum penalty per false claim submitted to a federal healthcare program?
- $500 per claim
- $13,000–$27,000 per claim (adjusted for inflation) (Correct answer)
- $5,000 per claim with no upper limit
- $1,000 per claim plus treble damages
Correct answer: $13,000–$27,000 per claim (adjusted for inflation)
The FCA imposes civil monetary penalties per false claim (adjusted periodically for inflation, currently in the range of approximately $13,000–$27,000) plus up to three times the government's damages.
Question 2: The qui tam provision of the False Claims Act allows private individuals to file suit on behalf of the government. What are these individuals called?
- Compliance officers
- Relators (whistleblowers) (Correct answer)
- Beneficiary advocates
- Medicare contractors
Correct answer: Relators (whistleblowers)
Qui tam relators, commonly called whistleblowers, can file FCA suits on behalf of the government and receive a portion of any recovered funds if the government succeeds.
Question 3: Under HIPAA's Breach Notification Rule, a covered entity must notify affected individuals of a breach of unsecured PHI within how many days of discovering the breach?
- 30 days
- 60 days (Correct answer)
- 90 days
- 180 days
Correct answer: 60 days
HIPAA's Breach Notification Rule requires covered entities to notify affected individuals within 60 days of discovering a breach of unsecured protected health information.
Question 4: A case manager is concerned that a colleague shared a patient's diagnosis with the patient's employer without consent. This would violate which HIPAA rule?
- HIPAA Security Rule
- HIPAA Privacy Rule (Correct answer)
- HIPAA Enforcement Rule
- HIPAA Omnibus Rule
Correct answer: HIPAA Privacy Rule
The HIPAA Privacy Rule governs the use and disclosure of protected health information; disclosing a patient's diagnosis to an employer without authorization or legal basis is a Privacy Rule violation.
Question 5: A patient enrolled in Medicaid is denied a service by the managed care plan. Under federal Medicaid managed care regulations, the plan must provide notice of the denial and the right to appeal. What is the required timeframe to resolve a standard appeal?
- 7 calendar days
- 30 calendar days (Correct answer)
- 45 calendar days
- 90 calendar days
Correct answer: 30 calendar days
Federal Medicaid managed care regulations require plans to resolve standard internal appeals within 30 calendar days of receiving the appeal.
Question 6: The Olmstead decision (1999) requires states to provide community-based services to individuals with mental disabilities when appropriate. How does this Supreme Court ruling primarily affect case managers?
- It prohibits all inpatient psychiatric admissions
- It mandates offering least restrictive community placement when clinically appropriate and the individual agrees (Correct answer)
- It requires states to fund unlimited home care services
- It eliminates nursing home options for Medicaid recipients
Correct answer: It mandates offering least restrictive community placement when clinically appropriate and the individual agrees
Olmstead requires states to place individuals with disabilities in community settings rather than institutions when treatment professionals determine it is appropriate, the individual does not oppose it, and it can be reasonably accommodated.
Question 7: Under the ADA and Section 504 of the Rehabilitation Act, healthcare providers receiving federal funding must provide reasonable accommodations to patients with disabilities. Which of the following is an example of a required accommodation?
- Providing luxury amenities to disabled patients
- Offering qualified sign language interpreters for deaf patients at no charge (Correct answer)
- Eliminating all cost-sharing for disabled beneficiaries
- Assigning a personal nurse aide to all patients with mobility limitations
Correct answer: Offering qualified sign language interpreters for deaf patients at no charge
Providing qualified sign language interpreters to deaf patients is a required reasonable accommodation under the ADA and Section 504, ensuring effective communication in healthcare settings.
CCM Healthcare Regulations and Compliance 4
A case manager working for a managed care organization must understand the False Claims Act (FCA).
Under the FCA, what is the minimum penalty per false claim submitted to a federal healthcare program?