CCMC Exam 26-50

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.

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.

A: Pertussis, more commonly called whooping cough, is listed as a reportable disease by the Centers for Disease Control (CDC).

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.

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.

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.

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.

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.

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.

A: When considering documentation, the physician is the agent of discharge. Documentation should never imply that the case manager discharged the patient.

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: 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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: 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.