CCM EXAM PREP - ALL TOPICS WITH COMPLETE SOLUTIONS 100% 2023/2024
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Course
CCM
Institution
CCM
CCM EXAM PREP - ALL TOPICS WITH COMPLETE SOLUTIONS 100% 2023/2024
Case management
a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client's health and human services needs.
Case Management Characterist...
CCM EXAM PREP - ALL TOPICS WITH COMPLETE
SOLUTIONS 100% 2023/2024
Case management
a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the
options and services required to meet the client's health and human services needs.
Case Management Characteristics
characterized by advocacy, communication, and resource management and promotes quality and
cost-effective interventions and outcomes.
Glagow Coma Scale
Client assessment tool that measures level of coma in the acute phase of injury it is an objective way
of recording the conscious state of a person. Eye opening, Best verbal, best motor. < 8 coma, 13-15
mild injury.
Strengths Based Model
assesses clients capacities and potential resources as well as problems and current unmet needs.
Eliciting capacities and potential resources as well as problems and current unmet needs.
Independent Living Model
sees a disability as a construct of society
Medicare Prospective Payment System
hospitals paid a pre-determined rate for each Medicare admission. Each patient is classified into a
DRG.
PHQ-9
Client assessment tool for depression
Braden Scale
Client assessment tool for pressure sore risk
Clinical Pathway
Structured multidisciplinary CM plan designed to support the implementation of specific clinical
guidelines and protocols. They are maps that guide the healthcare team on usual treatment patterns
related to common diagnoses, conditions and procedures e.g., CHF
SF-36
Client assessment tool to measure physical and mental health.
Medicare
Established in 1965 under Title XVIII or Social Security Act. Four Parts A-hospital insurance, B-medical
insurance (doctors visits), C-Medicare Advantage program in a private plan such as HMO, D-
prescription drug benefit
,Medicare Benefits and Cost Sharing
Not covered are: Acupuncture, chiropractor, cosmetic, custodial home care, dental care, DME
convenience, hearing aids, eyeglasses, foot care, meals on wheels, personal convenience, prescription
drugs, private nurses, routine physical, vision
areas of accountability of case management
clinical/outcome
financial
functional/outcome
satisfaction
behavior
process
*episode or continuum
**individual or population
Measuring performance: Process
The measure of how many pts receive a treatment or service i.e. vaccinations, screenings, ex. diabetic
foot exam ALSO practitioner's practice conforming to practice standards.
Measuring performance: Functional outcome
The measure reflects the health state of a patient as a result of health care ex. increased
independency in ADLs, mobility
Measuring performance: Clinical outcome
The measure reflects the health state of a patient as a result of health care ex. blood pressure goals
ex. HgA1c level, wound healing
Measuring performance: behavioral 'process'
ex. self-monitoring of blood sugar
Measuring performance: Financial
ex. fewer ED visits, ALOS decreased
Women's Health and Cancer Rights Act of 1998
1. Part of Omnibus Appropriations Bill. 2. required group health plans to provide coverage for
mastectomies and provide certain reconstructive related services following mastectomies.
Women's health and cancer rights act coverage
1. reconstruction of the breast. 2. surgery and reconstruction of the other breast 3. breast prothesis
4. treatment for physical complications attendant to the mastectomy
Women's health and cancer rights act prohibitions
Health plans are not allowed to deny anyone coverage for the sole reason of avoiding the
requirements of the act AND cannot induce a physician to limit the care that is required under the act
by penalizing or limiting reimbursement to the physician.
Can states modify HIPAA's portability requirement
,Yes. HIPAA requirements do not supercede state requirements. Stricter laws prevail. States can 1.
shorten the 6 month look back period. 2. shorten 12 month maximum pre-existing condition exclusion
period.3. increase the 63 day/significant break in coverage 4. increase 30 day period for newborns,
adopted children, children placed in adoption and pregnant women. 5. Expand the prohibitions on
conditions and people to whom a pre-existing condition exclusion period may be applied beyond
exceptions. 6. reduce additional special enrollment periods. 7. reduce maximum HMO affiliation
period to less than 2 months.
Break in coverage
63 days or longer that a subscriber has been without health insurance coverage (not including waiting
periods)
Waiting period
period of time specified by health insurance contract that occurs between signing up for insurance
and the beginning of health insurance coverage. Cannot be counted as creditible coverage time.
Individuals can use COBRA from their previous employers for health insurance
Establishing waiting period
HIPAA does not prohibit plans from establishing a waiting period. But the waiting period and the pre-
existing conditions exclusions must start at the same time and run concurrently.
Creditable Coverage
For the purpose of the Health Insurance Portability and Accountability Act, coverage under virtually
any type indivual or group health care plan without a break in coverage of 63 days or more. Cannot be
taken into account when determining a significant break in coverage. Only coverage after the 63 day
break will be counted. Any coverage before the 63 day break will not be considered.
COBRA
Consolidated Omnibus Budget Reconciliation Act; law to provide terminated employees or those who
lose insurance coverage because of reduced work to be able to buy group insurance for themselves
and their families for a limited amount of time.
Certification of creditable coverage
Documentation that is provided automatically by the plan or issuer when the individual loses
coverage or becomes entitled to elect COBRA continuation coverage and when an individual's COBRA
continuation covearage ceases ; Be provided if requested before loss of coverage or within 24 months
of loss of coverage. May be provided through use of model certificate
Nondiscrimination requirements
Inividuals cannot be excluded from coverage under the terms of the plan based on specified factors
related to health status. Health plans cannot establish rules of eligibility based on healht status
related factors" such as health status, medical condition, claims experience, receipt of health care,
medical history, genetic information, evidence of insurability or disablity. Insurer cannot drop a
patient from coverage because it knows that the patient will require a liver transplant next year.
Cannot charge more for premiums based on health status.
Security of health information and electronic signature standards
provides a uniform level of protection of all health information that is housed or transmitted
electronically. pertains to the individual.
, Tax Equity and Fiscal Responsibility ACT of 1982
the purpose of this act is to control the rising cost of providing health care services to medicare
beneficiaries and has incentives for cost containment. The act:1. established a case based
reimbursement system (DRG) payment system determined the cost of care for selected diagnoses
while also placing limits on rate increases in hospital venues. 2. Exempted medical rehabilitation from
DRGs. Rehabiliation would continue as a cost based reimbursement system with limits. 3. Amended
social security act so that group health plans pay before medicare for active employees 65-69 years
old and for their spouses in the same age group. 4. revised Age discrimination act by requiring
employers to offer health benefits to active employees 65-69 and their spouses in the same age
bracket. 5. establish peer review organizations to reduce costs associated with the hospital stays of
medicare and medicaid patients. Also established hospice benefit.
The Mental Health Parity Act of 1996
A statute that forbids health plans from placing lifetime or annual limits on mental health coverage
that are less generous than those placed on medical or surgical benefits. Excluded substance abuse. If
a plan does cover mental health, it cannot set a separate dollar limit from medical care. Other limits
allowed: limited number of annual outpatient visits; Limited number of annual inpatient days; a per
visit fee; Higher deductibles and copayments without parity in medical and surgical benefits. If a
parity would require an increase of 1% or more in its health care costs, the plan would be exempt.
The Pregnancy discrimination act
is an amendment to Title VII stating that employment discrimination based on pregnancy, childbirth,
or related medical conditions is prohibited as a form of sex discrimination
Newborns and Mother's Health Protection Act of 1996
Health plans may not restrict benefits for any hospital length of stay in connection with child birth for
new born or her bother to less than 48 hours following a normal vaginal delivery or less than 96 hours
following a delivery by cesarean section. They may not require providers to request for authorization
for up to 48/96 hours . May not increase an individuals coinsurance for any later portion of a 48
hour /96 hour hospital stay. 3. they cannot provide monetary payments to encourage a mother to
accept less than minimum protections available under NMHPA. They cannot penalizeor other wise
reduce or limit the reimbursement of an attending provider because the provider furnished care to a
mother or newborn in accordance to NMHPA. They cannot provide monetary or other incentives to
an attending provier to induce the provider to furnish care to a mother or new born in a manner
inconsistent with the NMHPA.
The Mental Health Parity and Addiction Equity Act of 2008
MHPAEA preserves the MHPA protections and adds significant new protections, such as extending the
parity requirements to substance use disorders. Although the law requires a general equivalence in
the way MH/SUD and medical/surgical benefits are treated with respect to annual and lifetime dollar
limits, financial requirements and treatment limitations, MHPAEA does NOT require large group
health plans or health insurance issuers to cover MH/SUD benefits. The law's requirements apply only
to large group health plans and health insurance issuers that choose to include MH/SUD benefits in
their benefit packages. However, the Affordable Care Act builds on MHPAEA and requires coverage of
mental health and substance use disorder services as one of ten EHB categories
Exceptions to MHPAEA 2008
Except as noted below, MHPAEA requirements do not apply to:
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