CCM Healthcare Regulations & Compliance 3 — Questions and Answers
Question 1: A care manager working in a managed care organization receives a request to deny coverage for a service deemed medically necessary by the treating physician. What regulatory framework governs the appeal process?
- COBRA regulations
- State and federal utilization review and external review laws (Correct answer)
- EMTALA requirements
- Stark Law exemptions
Correct answer: State and federal utilization review and external review laws
State utilization review laws and federal requirements under the ACA mandate specific internal appeal and external independent review processes when coverage for medically necessary services is denied.
Question 2: The Medicare Conditions of Participation (CoPs) for home health agencies require that a plan of care be reviewed and signed by a physician at least every:
- 30 days
- 60 days (Correct answer)
- 90 days
- 120 days
Correct answer: 60 days
Medicare CoPs require that the home health plan of care be reviewed by the physician and agency at least every 60 days, coinciding with the certification period.
Question 3: Which federal law prohibits discrimination based on race, color, national origin, disability, age, and sex in health programs receiving federal financial assistance?
- Title VII of the Civil Rights Act
- Section 1557 of the Affordable Care Act (Correct answer)
- The Hill-Burton Act
- Title II of the ADA
Correct answer: Section 1557 of the Affordable Care Act
Section 1557 of the ACA is the first federal civil rights law prohibiting discrimination based on multiple protected characteristics specifically in health programs and activities receiving federal financial assistance.
Question 4: What is the primary purpose of a Business Associate Agreement (BAA) under HIPAA?
- To authorize the release of PHI to family members
- To establish the contractual obligation of vendors handling PHI to protect that information (Correct answer)
- To document a patient's consent for treatment
- To satisfy Medicare billing requirements
Correct answer: To establish the contractual obligation of vendors handling PHI to protect that information
A BAA is a contract between a HIPAA covered entity and a business associate that establishes the permitted uses of PHI and ensures the business associate will safeguard the information.
Question 5: Under the Omnibus Budget Reconciliation Act (OBRA) 1987, nursing facilities must conduct a comprehensive assessment of each resident using which standardized tool?
- InterRAI Community Health Assessment
- Minimum Data Set (MDS) (Correct answer)
- Outcome and Assessment Information Set (OASIS)
- Functional Independence Measure (FIM)
Correct answer: Minimum Data Set (MDS)
OBRA 1987 mandates that nursing facilities use the Minimum Data Set (MDS) as part of the Resident Assessment Instrument to conduct comprehensive assessments for care planning.
Question 6: The OIG Work Plan is most useful to a care manager compliance officer because it:
- Lists all providers currently under investigation
- Identifies areas where the OIG intends to focus its audit and enforcement activities (Correct answer)
- Provides billing codes approved for the current year
- Establishes safe harbors for anti-kickback arrangements
Correct answer: Identifies areas where the OIG intends to focus its audit and enforcement activities
The OIG Work Plan outlines planned audits, evaluations, and inspections so that healthcare organizations can proactively assess their own compliance in those high-risk areas.
Question 7: Which element is NOT required for a valid informed consent in most US jurisdictions?
- Disclosure of risks and benefits
- Discussion of alternatives to the proposed treatment
- Patient's agreement to waive future liability (Correct answer)
- Patient's voluntary agreement to proceed
Correct answer: Patient's agreement to waive future liability
Valid informed consent requires disclosure, comprehension, capacity, and voluntary agreement — it cannot include a waiver of the patient's legal rights, which courts generally find unenforceable.
CCM Healthcare Regulations & Compliance 3
A care manager working in a managed care organization receives a request to deny coverage for a service deemed medically necessary by the treating physician.
What regulatory framework governs the appeal process?