An insurance plan that supplements services not covered by Medicare is known as:
b. catastrophic coverage
C: Medigap plans are insurance plans that supplement services not covered by Medicare.On the other hand, Medicaid is federally funded insurance for the poor. Capitation is the periodic fee paid to a healthcare practice by each member enrolled in a health plan.
Which of the following is true about reporting elder abuse?
a. The person reporting the abuse can be sued for slander
b. Reporting abuse is optional
c. Neglect is not considered a form of abuse
d. Exploitation of property is a form of abuse
D: Exploitation of property refers to an illegal use of a vulnerable adult's resources for personal profit This is a form of elder abuse that has several forms such as abuse of joint accounts and forgery. As long as a person reports abuse in good faith, he is protected from slander or libel claims. Reporting of abuse is mandatory.
According to the CDC, which of the following is a reportable disease?
b. Breast cancer
d. Cystic fibrosis
A: Pertussis, more commonly called whooping cough, is listed as a reportable disease by the Centers for Disease Control (CDC).
Payment based on a fixed daily dollar amount is known as:
a. per diem reimbursement
b. cost-based reimbursement
d. fee for service
A: The question defines a per-diem reimbursement. A cost-based reimbursement refers to actual costs of a patient's care. In fee for service, the provider bills the insurance company and the company pays for services. Capitation is a fixed monthly payment paid to a provider in advance of services.
The medical term for difficulty swallowing is:
D: The term for difficulty in swallowing is dysphagia. Dysphasia, on the other hand,refers to an absence of language function. Aphakia is an ophthalmologic term referring to the absence of the ocular lens. Lastly, akathisia is an abnormal level of agitation or restlessness.
Which of the following is most characteristic of assertiveness in a case managementsituation?
a. Assertiveness specifically directs you to do the most important task first
b. Assertiveness allows you to act instead of react in a particular situation
c. Assertiveness allows you to send messages using nonverbal cues such as posture andfacial expressions.
d. Assertiveness allows you to act as a referee
B: Assertiveness is an important part of communication and is a desirable skill for a case manager because of frequent encounters with tense situations. It simply gets the patient's needs met. Answer A describes prioritization; answer C describes nonverbal communication; and acting as a referee falls in the.realm of conflict resolution.
Which of these statements is true about hospice care?
a. Hospice care is solely for patients with terminal malignancies
b. Hospice is for patients who have six or fewer months to live
c. In hospice, all further medical treatment has been stopped, including palliation
d. Hospice care is for any terminal condition
D: Answers A and B are common misconceptions. Hospice is for patients with any terminal condition. Answer B is incorrect because it is difficult to know exactly how much longer a terminal patient will live. Even in the face of discontinuing aggressive therapy,patients in hospice care should receive palliative care to maximize comfort.
Which of the following is NOT one of the stages of the case management process?
a. implementation of the case management plan
b. medical decision making
B: Case managers do not make medical decisions. That is the domain of the physician.Stages of the case management process include implementation of the case management plan, follow-up, assessment, problem identification, coordination of the case plan, and continuous monitoring and reevaluation.
All of the following describe clinical pathways EXCEPT:
a. clinical practice guidelines
b. multidisciplinary in nature
c. proactive setting of plans for a specific diagnosis
d. a form of care coordination
A: Clinical pathways help standardize care for a particular diagnosis. The pathways are multidisciplinary in nature and often significantly improve outcomes. Pathways include a timeline for providing interventions, whereas guidelines typically do not follow strict timelines.
From the standpoint of documentation, the patient's discharge agent is the:
b. case manager
c. multidisciplinary team
d. social worker
A: When considering documentation, the physician is the agent of discharge. Documentation should never imply that the case manager discharged the patient.
A prospective review
a. is performed while the patient is still in the facility
b. is performed after patient discharge from a facility
c. determines if admission to a facility is medically necessary
d. is a quality control measure
C: A prospective review is also known as precertification. It occurs before services are delivered. The purpose is to determine if admission to a facility is medically necessary. On the other hand, a review done after discharge is a retrospective review. Retrospective reviews are useful evaluation tools for quality control. A concurrent review occurs while the patient is still in the facility.
A patient with terminal cancer needs expensive treatment, but is at the end of insurance coverage. The family has no financial resources. The case manager is now faced with a dilemma between the best interests of the patient and the best interests of the payer. This type of conflict is called:
a. focus of advocacy
b. conflict of duties
c. supremacy of values
A: This scenario describes a common case management dilemma called focus of advocacy. Supremacy of values refers to determining whether the values of the patient,family, case manager, or insurer should take precedence. A conflict of duties exists when a case manager causes harm to others while carrying out a client's wishes.
A patient has received a complete description of a medical treatment regimen including risks, hazards, complications, and prognosis. What is this type of explanatory procedure called?
a. DSM-IV guidelines
b. risk management
c. full disclosure
d. vicarious liability
C: The process of giving a patient a complete description of medical treatment is called full disclosure. In vicarious liability, a person can be held liable for harm done to another person. Risk management assesses, identifies, and controls risks that originate from operational factors. DSM-IV guidelines are diagnosis and management guidelines for psychiatric disorders.
An adult patient who sustained a spinal cord injury has developed depression, anxiety,and feelings of anger. A case manager should recognize this catastrophic injury as a:
a. change-agent illness
b. maladaptive situation
c. behavioral disorder
A: Any illness or injury that changes a person's life is called a change-agent illness. It may affect a patient socially, physically, or psychologically. Patients often feel a sense of fear, loss, and dependency. Anxiety and depression are common as well.
Which of the following is considered an ancillary service?
a. nursing care
b. physician care
c. occupational therapy
d. obstetric care
C: Ancillary services are those services needed by a patient in addition to nursing and medicine. These include things such as physical therapy, occupational therapy, nutrition, radiology, and laboratory services.
An infant is born at home. The mother and baby present to the hospital two hours after birth and are admitted. According to the Newborns' and Mothers' Health Protection Act(NMHPA), the length of the hospital stay is determined by starting at:
a. the time a physician initially sees the mother
b. the time of birth of the infant
c. the time of admission
d. the time the patient's room is ready for occupancy
The presence of one or more disorders in addition to a primary disease is called a/an:
b. red flag
c. preexisting condition
d. Axis II disorder
A: A co-morbidity is a disorder that occurs in addition to a primary disease. For example,diabetics often have comorbidities such as heart disease, nephropathy, or retinopathy. The term Axis II is a classification section in the DSM-IV psychiatric manual and refers to personality disorders and mental retardation. A preexisting condition is a physical or mental illness or disability that you have prior to enrolling in a health plan.
All of the following are true about Medicare Select EXCEPT:
a. Medicare Select is a Medicare supplemental health insurance product
b. Medicare Select policies are managed care plans
c. Medicare Select plans are higher in cost than traditional Medigap plans
d. with Medicare Select, a patient is required to use specific hospitals, clinics, and sometimes even specific physicians
C: Medicare Select plans have lower premiums than Medigap policies because of their requirement to use specific facilities and, sometimes, specific physicians. All of the other statements are true.
Which of these is NOT covered according to the Balanced Budget Act of 1997?
a. annual prostate cancer screening for patients over age SO
b. bone density tests for patients at risk for osteoporosis
c. diabetes education
d. one Pneumovax vaccine yearly
D: Choices A, B, and C are procedures all covered according to the Balanced Budget Act of 1997. Pneumovax is covered, but only once in a lifetime, not every year.
Which of these is an eligibility criterion for the SCHIP program?
a. patient over age 65
b. low income
c. having supplemental insurance
d. outpatient coverage only
B: The State Children's Health Insurance Program (SCHIP) is an insurance program for children. To be eligible for SCHIP, federal guidelines must be met The child's family must be of low-income status, not qualify for Medicaid, and not have any medical insurance. SCHIP does cover inpatient services in addition to outpatient services.
An adult patient has been hospitalized for several weeks. The staff has met to discuss the severity of the patient's illness and level of medical stability. This type of review is called a:
a. concurrent review
b. continued stay review
c. EPSDT review
d. prospective review
B: A continued stay review occurs at specific intervals during a hospital stay. Alternately,a concurrent review is performed to determine treatment necessity and appropriateness while the patient is still in the hospital. Early Periodic Screening, Diagnosis, and Treatment (EPSDT) exams are for children. A prospective review is a pre-certification process that takes place before services are rendered to the patient.
Which of the following is true about case management (CM) in a school setting?
a. CM deals mostly with crisis management
b. CM responds to problems rather than addressing prevention
c. CM is a random collection of interventions
d. CM involves meeting with patients and families on a regular basis to prevent
D: Case management in the school is a long-term relationship with a child and his family,usually lasting throughout the academic year. It includes comprehensive involvement andcoordination of services to meet a child's healthcare needs. It is far more than crisis and problem management. Interventions are organized and not random. The goal of casemanagement in schools is to decrease fragmented care and to improve the quality of life for children with chronic illnesses.
Which of the following is true?
a. The terms case management and managed care are equivalent
b. Case management is a uniform process for all patients
c. Case management is a highly individualized process
d. Case management aims to identify the least cost intensive patients
C: Case management is a highly individualized process, because no two patients areexactly alike in their needs. Contrary to what answer choice D states, case managementaims to identify the most cost-intensive patient
An insurance company has purchased insurance to protect itself from a highly expensivecase. This type of insurance is called:
a. stop loss
c. deferred liability
d. third-party liability
A: Stop loss, also known as reinsurance, is insurance bought by an insurance company to protect itself from highly expensive cases. There are some diagnoses that are statistically proven to be extremely expensive, such as organ transplantation and AIDS.
A physician performed a Tensilon test for myasthenia gravis on a hospitalized patient.The number 95858 was entered to bill for the procedure. This number is known as a:
a. CPT code
b. ICD-10 code
c. DRG code
d. Medicare code
A: A Current Procedural Terminology (CPT) code is a numeric code that describes a diagnostic, medical, or surgical service. CPT codes describe uniform information about medical services and procedures for the benefit of physicians, coders, and payers. ICD-10 codes are alphanumeric designations that represent diseases or conditions.