CCM Healthcare Regulations and Compliance 4

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?

Accepted Answer

$13,000–$27,000 per claim (adjusted for inflation)

Answer

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?

Accepted Answer

Relators (whistleblowers)

Answer

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?

Accepted Answer

60 days

Answer

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?

Accepted Answer

HIPAA Privacy Rule

Answer

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?

Accepted Answer

30 calendar days

Answer

Federal Medicaid managed care regulations require plans to resolve standard internal appeals within 30 calendar days of receiving the appeal.

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Practice Test

CCM Healthcare Regulations and Compliance 4