Certified Case Manager Healthcare Regulations and Compliance 1 Flashcards
6 cards from real CCM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Certified Case Manager Healthcare Regulations and Compliance 1 flashcards as text
Which federal law requires healthcare providers to maintain the privacy and security of patients' protected health information (PHI)?
Answer: HIPAA
HIPAA (Health Insurance Portability and Accountability Act) establishes national standards for protecting PHI, governing how healthcare providers, health plans, and clearinghouses must safeguard patient information and limiting its disclosure without patient authorization.
Under Medicare's Conditions of Participation, what is a hospital's primary obligation regarding discharge planning?
Answer: Hospitals must identify patients who need post-acute care and develop a discharge plan in collaboration with the patient and their caregivers
Medicare's Conditions of Participation require hospitals to identify patients who need post-discharge services early in the stay and to develop a patient-centered discharge plan with input from the patient, family, and caregivers to ensure a safe transition to the appropriate level of care.
What does the False Claims Act primarily prohibit in the context of healthcare?
Answer: Submitting fraudulent claims for payment to federal healthcare programs
The False Claims Act prohibits knowingly submitting false or fraudulent claims for payment to federal programs like Medicare and Medicaid. It includes a 'qui tam' provision allowing private citizens (whistleblowers) to file suit on behalf of the government and share in any recovery.
Which regulation governs the rights of individuals with disabilities to access healthcare facilities and services without discrimination?
Answer: Section 504 of the Rehabilitation Act and the Americans with Disabilities Act (ADA)
Section 504 of the Rehabilitation Act and the ADA together prohibit discrimination against people with disabilities in healthcare settings, requiring providers to offer reasonable accommodations and ensure physical and programmatic accessibility.
A case manager discovers that a colleague is accepting gifts from a home health agency in exchange for referrals. Under the Anti-Kickback Statute, which action is most appropriate?
Answer: Report the conduct through the organization's compliance program or to the Office of Inspector General
The Anti-Kickback Statute prohibits any remuneration intended to induce referrals for federally reimbursed services. Gifts in exchange for referrals are a violation regardless of amount or profession. The correct action is to report through compliance channels or the OIG, as case managers have an ethical and legal obligation to address fraud.
What is the primary purpose of the Utilization Review (UR) process as it relates to healthcare compliance?
Answer: To evaluate the medical necessity, appropriateness, and efficiency of healthcare services in accordance with payer requirements
Utilization Review is a compliance and quality management process that evaluates whether healthcare services meet established criteria for medical necessity and appropriateness. It helps ensure resources are used efficiently and that services are reimbursable under applicable payer policies, protecting both patients and organizations from inappropriate billing.