CCM Exam 315 Questions with Verified Answers
HMO - CORRECT ANSWER health maintenance organization
ACO - CORRECT ANSWER Accountable Care
... [Show More] Organization
Viatical Settlements - CORRECT ANSWER ability to sell own insurance policy
CHAMPVA - CORRECT ANSWER Civilian Health and Medical Program of the Veterans Administrationtr
CHAMPVA for Life - CORRECT ANSWER provides healthcare benefits to families of permanently disabled veterans, or killed in line of duty, not eligible for tricare. Covers 65 or older, is a Medicare supplement.
TRICARE - CORRECT ANSWER is a U.S. government health insurance plan for active military personnel, national guard, reserves, retirees, their families and some former spouse's.
TRICARE for Life - CORRECT ANSWER primarily a supplemental insurance with those with Medicare A & B coverage, &eligible for TRICARE in US. Is the primary insurance overseas.
advance directives - CORRECT ANSWER A signed document indicating that the person's wishes regarding care during dying.
ASO - CORRECT ANSWER administrative services only, and insurance company or TPA that provides administrative services for an employer group.
Adverse Events - CORRECT ANSWER any untoward occurrences not of natural consequences.
Advocacy - CORRECT ANSWER support; active pleading on behalf of someone or something
Alternate level of care - CORRECT ANSWER level of care used safely in place of current level, determined by acuity.
Assessments - CORRECT ANSWER The process of collecting in-depth information about a persons situation and function to identity needs.
assistive device - CORRECT ANSWER tool, software, or hardware to assist in performing daily activities
Assistive technology - CORRECT ANSWER equipment or products used by individuals with disabilities to improve functioning in activities
Autonomy - CORRECT ANSWER person's right to self determination and independence
Beneficence - CORRECT ANSWER Doing good or causing good to be done; kindly action
Beneficiary - CORRECT ANSWER a person who derives advantage from something, especially a trust, will, or life insurance policy.
Benefit package - CORRECT ANSWER the sum of services a health plan, government agency, or employer contracts to provide.
Benefits - CORRECT ANSWER the amount payable by the insurance company to a claimant or beneficiary under claimant s coverage.
Brain injury - CORRECT ANSWER Any brain damage that impairs normal functioning of the brain, either temporarily or permanently
Burden of proof - CORRECT ANSWER the obligation facing a persuasive speaker to prove that a change from current policy is necessary
Capitation - CORRECT ANSWER fixed amount of money per member-per-month paid to care provider for covered services.
CARF - CORRECT ANSWER commission on accreditation of rehabilitation facilities, private, non profit organization that establishs standards of quality services for people with disabilities.
Carve outs - CORRECT ANSWER services that are excluded from a provider contract, provider not responsible for services carved out of contract
Caseload - CORRECT ANSWER total number of patients followed by a case manager at any point in time.
case management - CORRECT ANSWER collaborative process that assesses, plans, implements, coordinates, monitors &evaluates options and services to meet needs of individuals.
Case Management System - CORRECT ANSWER a computer program that helps a counselor organize information used to serve a specific client
Case mix index (CMI) - CORRECT ANSWER sum of DRG-relative weights of all patients seen in years time divided by patients hospitalized
Case rate - CORRECT ANSWER rate of reimbursement that packages pricing for a certain category of services.
Catastrophic case - CORRECT ANSWER case with complexities, multiple providers, and services that will be costly to patient and providers
Claims - CORRECT ANSWER request for payment or reparation for a loss covered by insurance contract.
Clinical pathways - CORRECT ANSWER a timeline of patient care activities and expected outcomes of care.
Coinsurance - CORRECT ANSWER a provision under which both the insured and the insurer share the covered losses, cost-sharing
Competence - CORRECT ANSWER the ability to do something successfully or efficiently, mental capacity
Concurrent review - CORRECT ANSWER method of reviewing patient care and services during a hospital stay to validate care necessity
Comorbidity - CORRECT ANSWER the co-occurrence of two or more disorders in a single individual
Continuous Quality Improvement - CORRECT ANSWER CQI, process of ongoing review to improve quality of healthcare services
Coordination of benefits (COB) - CORRECT ANSWER process to prevent duplication of payments when subscriber has coverage from multiple sources
Copayment - CORRECT ANSWER a fixed fee paid by the patient at the time of service, example office visit or prescription
Credentialing - CORRECT ANSWER ensures competence of practitioners, process to approve providers
Cultural competence - CORRECT ANSWER behaviors, attitudes, and policies that come together on a continuum to work in a diverse setting
custodial care - CORRECT ANSWER care provided primarily to assist patient in meeting activities of daily living, don't require Skilled nursing care
Current Procedural Terminology - CORRECT ANSWER A comprehensive list of codes used by physicians to bill for procedures and services
Deductible - CORRECT ANSWER amount of expenses that must be paid out of pocket before an insurers payments begin
Denial - CORRECT ANSWER claim denied due to inability to justify services medically necessary
Diagnostic related groups, DRG - CORRECT ANSWER Fixed fee based on diagnosis, give information about illness pre-set rate they allow
Disability - CORRECT ANSWER any lost, absent, or impaired physical or mental function
Disability income insurance - CORRECT ANSWER Provides payments to replace income when an insured person is unable to work
Eligibility - CORRECT ANSWER the qualify factor or factors that must be met before a pt receives benefits
Ergonomics - CORRECT ANSWER The study of how the body works in order to design better tools
Creditable coverage - CORRECT ANSWER references the time during which a person is covered by health insurance
Break in coverage - CORRECT ANSWER 63 days or more without health insurance
Exclusive provider organization (EPO) - CORRECT ANSWER a managed care plan that provides benefits for care given only by network providers
Fee-for-service (FFS) - CORRECT ANSWER an insurance payment system where providers are paid for each service, also called indemnity plan
Formulary - CORRECT ANSWER A list of prescription drugs approved by a health plan.
Functional Capacity Evaluation FCE - CORRECT ANSWER examination of a worker's physical abilities to perform required tasks
Functional job analysis - CORRECT ANSWER defines the job requirements, both essential and non essential duties
Gatekeeper - CORRECT ANSWER a PCP that manages all referrals for speciality care and other services
Group Model HMO - CORRECT ANSWER HMO contracts with a group of physicians to provide services for a fixed monthly fee per enrollee
Independent Practice Association (IPA) model - CORRECT ANSWER a legal entity(private practice) sponsored by physicians that contracts with HMO : bound by terms of contract
Network model - CORRECT ANSWER An organizational arrangement in which an HMO contracts with more than one medical group practice. A provider network
Staff Model HMO - CORRECT ANSWER group of physicians who work and are paid by the HMO and see only HMO patients
Handicap - CORRECT ANSWER condition that interferes with a person's ability to function normally
Health Insurance - CORRECT ANSWER Provides money to pay for health care for illness, injury, or in some cases preventive care.
Healthcare Maintenance Organization HMO - CORRECT ANSWER an organization that provides or arranges for coverage of health services for fixed fee
Hospice - CORRECT ANSWER A type of care for terminally ill patients; an organization that provides such care
ICD 10 - CORRECT ANSWER International Classification of Diseases, Tenth Edition, used for coding MR for reimbursement
Indemnity Benefits - CORRECT ANSWER the provider bills the patient for services, insurance reimburses patient
Informed Consent - CORRECT ANSWER consent given by patient, next of kin, legal guardian for services
Inpatient Rehabilitation - CORRECT ANSWER eligibility: tolerate 3 hours of therapy/day, require skilled service
Managed care - CORRECT ANSWER is an approach that has developed in response to rising health care costs
Levels of Care - CORRECT ANSWER the intensity of effort required to diagnose, treat, preserve or maintain an individuals functional status
Length of stay - CORRECT ANSWER The number of days a person stays in a healthcare facility.
JCAHO stands for: - CORRECT ANSWER joint commission on accreditation of health care organizations
Integrated delivery system - CORRECT ANSWER single group of organizations that provide care across a continuum of settings
Maximum Medical Improvement MMI - CORRECT ANSWER injured worker is at level physician determines further treatment will not change outcome
long term disability - CORRECT ANSWER insurance issue to an employee group or individual to replace a portion of an individual's income lost as a result of serious prolong illness during the normal work career
Malpractice Insurance - CORRECT ANSWER insurance to cover liability assumed during practice
malpractice - CORRECT ANSWER Improper care or treatment by health care professional. Wrong conduct, negligent.
Medicaid - CORRECT ANSWER a joint federal and state program that provides basic health insurance for persons with disabilities for or who received certain government benefits(ssi)
Medicare Part A - CORRECT ANSWER basically covers inpatient hospital expenses for patients who meet certain conditions
Medicare Part B - CORRECT ANSWER Outpatient care. Extends Medicare to supplemental treatments, and physicians
Minimum Data Set (MDS) - CORRECT ANSWER assessment to used in SNF to place patients in RUG to determine reimbursement
Medical durable power of attorney - CORRECT ANSWER a legal document that names a surrogate decision-maker in the event the patient is unable to make decisions
Network model HMO - CORRECT ANSWER HMO contract directly with IPA, medical groups & independent Physicians forming a provider Network, organized referrals
Nonmaleficence - CORRECT ANSWER do no harm
Per diem - CORRECT ANSWER daily allowance
Point of Service (POS) - CORRECT ANSWER a combination of a PPO and HMO plan using a contracted network of providers and PCP as Gate Keeper to control referrals. out-of-network services incur higher deductible
Pre-admission Certification - CORRECT ANSWER utilization review process that examines proposed Services before admission
Pre-Authorization/Pre-Certification - CORRECT ANSWER process of obtaining & documenting approval for health plan befor delivery of Medical Services
Preferred Provider Organization - CORRECT ANSWER PPO, preferred provider group/ organization where group of medical providers provide medical services on a negotiated fee
Primary care physician (PCP) - CORRECT ANSWER provider who assumes ongoing responsibility for overall health treatment of a patient
Prospective review - CORRECT ANSWER Reviewing possible hospitalization before admission to determine necessity and LOS
HEDIS HealthCare Effectiveness Data Information Set - CORRECT ANSWER performance measurement set for MCO to set quality of systems
Quality Assurance - CORRECT ANSWER Use of activities and programs ensuring quality of patient care
Quality Improvement - CORRECT ANSWER process used to identify and resolve deficiencies and improve care outcomes
Reasonable Accommodation - CORRECT ANSWER make an existing facility accessible and usable for individuals with disabilities; can include job adaptation for individuals
Resource utilization groups (RUGs) - CORRECT ANSWER classifiies SNF patients into 7 major hierarchies and 44 groups, based on MDS for reimbursement
Root Cause Analysis (RCA) - CORRECT ANSWER process to identify underlying factors that contribute to variation in outcomes in sentinel event
Risk Sharing - CORRECT ANSWER HMO &PROVIDER share financial risk/rewards of caring for plan members
Self-insured - CORRECT ANSWER an employer that meets the state legal and financial requirements to assume all of its health care costs for its employees
Staff Model HMO - CORRECT ANSWER Physicians are on the staff of the HMO and provide care exclusively for the health plan enrollees
Third Party Administrator (TPA) - CORRECT ANSWER an organization separate from the insurer that handles administrative functions such as review claims & UR
Veracity - CORRECT ANSWER truthfulness
Work Adjustment - CORRECT ANSWER use of simulated work activity to develop work behaviors, attitudes, characteristics
Work hardening - CORRECT ANSWER Rehab real/simulared work activities designed to restore physical function
Methadone - CORRECT ANSWER Strong opioid agonist, heroin treatment
stop loss - CORRECT ANSWER insurance that is brought by insurers to limit loss for Catastrophic, unpredictable incidents
Tort - CORRECT ANSWER a wrongful act or infringement of a right leading to civil legal liability
State children's health insurance program (SCHIP) - CORRECT ANSWER state insurance for low income. uninsured children not eligible for medicaid
Medicare - CORRECT ANSWER A federal program insurance: 65 or older, disabled, ESRD(dialysis or transplant)
Medicare Part A - CORRECT ANSWER Pays a 100% days 1-60 for each benefit period, patient pays deductible
Medicare Part D - CORRECT ANSWER Prescription Drug Coverage
Medicare part C - CORRECT ANSWER allows participants to choose a Medicare Advantage plan, HMO type coverage
Medigap - CORRECT ANSWER supplemental insurance plans that help pay expenses not covered by Medicare
benefit period - CORRECT ANSWER a specified amount of time during which benefits will be paid.
Rehabilitation Act of 1973 - CORRECT ANSWER Act that prohibits discrimination based on physical or mental disabilities.
American Disabilities Act - CORRECT ANSWER prohibits discrimination in employment , accommodatios of people with disabilities
Biofeedback - CORRECT ANSWER the process of learning to control bodily awareness or function, example HR
EMTALA - CORRECT ANSWER Emergency Medical Tx and Active Labor Act - anti-"dumping" law
EMTALA - CORRECT ANSWER federal law that requires emergency department to stabilize and treat regardless of ability to pay
Dual Diagnosis - CORRECT ANSWER when an individual is diagnosed with both a psychiatric disorder and a substance use disorder
Bereavement Counseling - CORRECT ANSWER type of psychotherapy that helps a person deal with grief after a loss
Stages of Change - CORRECT ANSWER 1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
Transtheoretical Model - CORRECT ANSWER behavioral model that describes stages of readiness for change
Respite Care - CORRECT ANSWER Temporary care that relieves caregivers of their responsibilities for a short period of time.
Case Management Society of America - CORRECT ANSWER international non for profit organizations dedicated to support the advancement of case management
Critical Pathways - CORRECT ANSWER carepath that create goals for patient to accomplish optimum outcomes; clinical pathway
Life Care Plan - CORRECT ANSWER Dynamic document which provides an organized plan for current and future needs of a person who experienced a catastrophic injury chronic illness/life change
Retrospective review - CORRECT ANSWER form of medical records review that is conducted after the patient is discharged
OASDI: Eligibility for Retirement - CORRECT ANSWER insurance program for Oasis virus and disability Center of Social Security Act
Medicare select - CORRECT ANSWER A HMO type policy that specifies the hospitals a patient must use, unless an emergency
ancillary services - CORRECT ANSWER Professional healthcare services such as radiology, laboratory, or physical therapy
SSI supplemental security income eligibility - CORRECT ANSWER disabled, blind, retirement age
Social Security disability insurance(SSDI) - CORRECT ANSWER a federal program that provides supplemental income to people who have employment restrictions due to disability
Failure to thrive - CORRECT ANSWER weight for age that falls below percentile
health literacy - CORRECT ANSWER the ability to obtain, communicate, process, understand and make health care decisions
Test of Functional Health literacy assessment (TOFHLA) - CORRECT ANSWER complex assessment consists of two parts (numbers/documents & reading comprehension) to assess health literacy
Rapid Estimate of Adult Literacy in Medicine (REALM) - CORRECT ANSWER assesses the ability of adult pt to read medical words& lay terms for illnesses & body parts
Polypharmacy in Older Adults - CORRECT ANSWER Inadvertent prescriptions from multiple medications from multiple providers
Reverse mortgage - CORRECT ANSWER an option for a patient who is a homeowner and 62 years of older to borrow against for health care needs
Accelerated Death Benefits - CORRECT ANSWER an insurance policy Rider allow an insurer personal with a terminal illness to use policy benefits prior to dying
Dementia - CORRECT ANSWER An abnormal condition marked by multiple cognitive defects that include memory impairment.
Actuarial study - CORRECT ANSWER is a statistical analysis of a population based on its utilization of specific is healthcare services and demographic trends
Appeals - CORRECT ANSWER formal process or request to reconsider Healthcare decision(denials)
Extra-contractual benefits - CORRECT ANSWER benefits not covered under the health plan but are given to the insured for cost savings
Pharmacy Benefit Management (PBM) - CORRECT ANSWER services used to control the cost of prescription drugs
COBRA - CORRECT ANSWER Consolidated Omnibus Budget Reconciliation Act insurance coverage after job loss
COBRA - CORRECT ANSWER ability to retain Insurance due to a catastrophic change ex: job loss, decreasing work, divorce, lasts up to 36 months at a higher rates
Mental Status Exam - CORRECT ANSWER broad preliminary assessment of behavior and mental state
PHQ-9 - CORRECT ANSWER assessment that evaluates degree of depression
DSM-IV - CORRECT ANSWER A guide used for the diagnosis of psychiatric and mental health disorders
Cost-benefit analysis - CORRECT ANSWER economic model that compares the monetary savings and benefits of a decision
Hard Savings - CORRECT ANSWER directly related to case manager's actions, ex: decrease length of stay, price negotiations
Soft savings - CORRECT ANSWER cost savings that can't be measured, ex: avoidance of hospital readmission
case management plan - CORRECT ANSWER plan developed by IDT Healthcare team in relations to Patient diagnosis problems and surgical procedures
First level reviews - CORRECT ANSWER conducted while the patient is in the hospital, care is review for appropriateness
Outcome and Assessment information set OASIS - CORRECT ANSWER a nursing assessment instrument completed by Home Health agencies at the time the patient has entered for Home Health Services score determines Home Health Resource Group (HHRG)
Quality Indicator - CORRECT ANSWER Measures of outcomes
Functional Independence Measures Instrument (FIM) - CORRECT ANSWER used in the Inpatient Rehab setting measures the individual level of Independence/ dependence in ADLs
Managed Care - CORRECT ANSWER is a Cost Containment Healthcare System overseen by an organization other than the physician or patient
Bundled reimbursement - CORRECT ANSWER care is reimbursed according to expected cost for a clinical episode of care
SSDI eligibility requires - CORRECT ANSWER individual must be unable to perform the work they previously did and the disability must be expected to last at least one year or result in death
Rancho Los Amigos - CORRECT ANSWER assessment to used to assess cognitive functioning after a traumatic brain injury
Axis I - CORRECT ANSWER Clinical disorders (depression, anxiety)
Axis II - CORRECT ANSWER personality disorders and developmental disorders
Axis III - CORRECT ANSWER General medical conditions
Axis IV - CORRECT ANSWER Psychosocial and environmental problems
Axis V - CORRECT ANSWER Global Assessment of Functioning that allows the clinician to rate the level of danger to one's self and functioning
Glasgow Coma Scale (GCS) - CORRECT ANSWER measures level of coma in the acute phase of an injury
Health risk assessment (HRA) - CORRECT ANSWER a tool to assess a patient's health status, risk of negative health outcomes, and readiness to change behaviors
HRA components - CORRECT ANSWER questionnaire, risk calculation, and feedback
Due diligence - CORRECT ANSWER reasonable steps taken by a person in order to avoid negligent action.
Pallative care - CORRECT ANSWER care for seriously ill persons focused on providing relief from symptoms
Disorientation - CORRECT ANSWER lack of awareness of self, place, and/or time seen in multitude of conditions
Benchmarking - CORRECT ANSWER Method of measuring quality by comparing performance against industry leaders
Case rate - CORRECT ANSWER rate of reimbursement that packages pricing for certain category of services
Sub-acute Care - CORRECT ANSWER level of care where patient doesn't require hospital care but more intensive than SNF services
Skilled Nursing Facility (SNF) - CORRECT ANSWER offers 24-hour skilled nursing and personal care also Rehab Services
Intermediate Care - CORRECT ANSWER level of care for patients who require more assistance and custodial care may require nursing supervision but do not need true skilled care
Home Health Care - CORRECT ANSWER health care services provided in a patient's home, to qualify patient must be homebound
Custodial care - CORRECT ANSWER assistance with personal and Home Care such as ADLs and IADLs, not skilled or licensed
Long-term care facilities - CORRECT ANSWER mainly provide assistance and care for elderly patients, usually called residents
Long-Term Acute Care Hospital (LTAC) - CORRECT ANSWER focus on patients who require stay more than 25 days and treatment of serious conditions: may improve to go home
Acute care - CORRECT ANSWER most intensive level of care which a patient is treated for brief episodes of critical condition or trauma
Health Coach - CORRECT ANSWER secondary prevention, already has chronic condition, focused on assisting them to attain their own healthcare goals
Ethnocentricity - CORRECT ANSWER based on the attitude that one's group is superior
Abuse - CORRECT ANSWER Physical, mental/emotional, or sexual mistreatment of one person by another
Neglect - CORRECT ANSWER active or passive failure to provide the basic care supervision or services necessary to avoid physical or emotional harm
forms of abuse - CORRECT ANSWER physical , emotional /psychological, Financial
Financial Resources alternatives - CORRECT ANSWER to pay for insurance and fees patients may use; long-term care insurance, accelerated death benefits, viatical settlements, reverse mortgages
Documentation - CORRECT ANSWER critical to case management
Medication reconciliation - CORRECT ANSWER must be completed to avoid or prevent polypharmacy
motivational interviewing - CORRECT ANSWER helps clients explore and resolve ambivalence and find the best possible solution
Developmental Disability - CORRECT ANSWER any mental & or physical disability that has an onset before age 22 and may continue indefinitely
American with Disabilities Act - CORRECT ANSWER prohibits discrimination against people with disabilities in employment, Transportation, public accommodation, communications & governmental activities
ADA Title I - CORRECT ANSWER employers with 15 or more employees are prohibited from discriminating against people with disabilities
Advocate - CORRECT ANSWER main focus of Case management
Primary nursing model of care - CORRECT ANSWER the same nurse provides comprehensive care for the member the entire period of care
Case management model of care - CORRECT ANSWER IDT group monitors and discusses patients health care progress, more cost-effective
Family-Centered Model of Care - CORRECT ANSWER collaborates with the family & healthcare team to support patient healthcare decisions
Public Health nursing model of care - CORRECT ANSWER focuses on an entire population that has similar health issues
Integrative model of care - CORRECT ANSWER IDT model of care that encompasses medical, psychosocial and social needs of the patient
Medical Home model - CORRECT ANSWER care focus on primary provider care and relationship between patient, family, and physician
chronic care model - CORRECT ANSWER focused on proactive evidenced based, population based, & patient-centered care for patients with chronic medical conditions
Workers Compensation - CORRECT ANSWER provides coverage of injury or illness that occurred while at work or work-related task
case management process - CORRECT ANSWER identify patients, assess problems, develop, Implement, evaluate, & terminate POC
Magnuson Model - CORRECT ANSWER model to determine the patient intensity or Acuity levels.
Broker model - CORRECT ANSWER standard model, design to identify needs of the client & access to identified resources
signs of abuse - CORRECT ANSWER unexplained bruising, malnutrition, unkempt, multiple ER visits
BATNA - CORRECT ANSWER Best Alternative To a Negotiated Agreement, allows CM to explore alternative solutions
Active listening - CORRECT ANSWER essential to negotiating , includes listening to direct and indirect communications
Uilization Review Accreditation Commission (URAC) - CORRECT ANSWER non-profit organization that provides accreditation to Health Care organizations
Goal of the URAC - CORRECT ANSWER to encourage continued Improvement in quality and efficient Healthcare Management to education and accreditation
National Quality Forum (NQF) - CORRECT ANSWER organization that's set standards used to measure public report Healthcare quality
Assistive Technology - CORRECT ANSWER array of devices that permit people with disabilities to improve their functioning
Non-maleficence - CORRECT ANSWER deals with the practitioner (do no harm)
OSHA - CORRECT ANSWER in the Department of Labor to maintain a safe and healthy work environment
Family and Medical Leave Act of 1993 (FMLA) - CORRECT ANSWER Requires employers to provide up to 12 weeks of unpaid leave for family and medical emergencies
Mental Health Parity Act of 1996 - CORRECT ANSWER prohibits lifetime or annual dollar limits on Mental Health Care unless same limits apply to medical/surgical tx
Newborns and Mothers Health Protection Act of 1996 (NMHPA) - CORRECT ANSWER an amendment to title VII of Civil Rights Act of 1964, that cover private/public hospitals length of stay following childbirth, pregnancy must be treated same as other employee related iilnesses
Women's Health and Cancer Rights Act of 1998 (WHCRA) - CORRECT ANSWER requires insurance coverage of breast reconstruction following mastectomy
HIPAA stands for - CORRECT ANSWER Health Insurance Portability and Accountability Act of 1996
HIPAA - CORRECT ANSWER Title I guarantees health insurance access portability and renewal, prohibits discrimination based on health status
Email communication - CORRECT ANSWER non-verbal communication
Wickline vs. State of California - CORRECT ANSWER found the CM's are liable for damage if their referral is careless and leads to patient harm
Methadone - CORRECT ANSWER used for the treatment of heroin addiction
Predictive Modeling - CORRECT ANSWER a data-mining technique used to predict future behavior and anticipate the consequences of change
Medicare eligibility - CORRECT ANSWER 65 or older, disabled(5month waiting period), Railroad retirement (24 +5months), ESRD
Medicare admission criteria for Inpatient Rehab - CORRECT ANSWER admitting Dx, recent loss of ADL, MD DX with potential Improvement, if previously in rehab has to have occurrence that shows pt can reestablish function
Prosthesis - CORRECT ANSWER An artificial device to replace/augment a missing/impaired part or all of missing body part
Orthosis - CORRECT ANSWER a device used to support a weak or ineffective joint or muscle to restore function
DME criteria - CORRECT ANSWER used for medical reason, usually not useful for the sick/injured, long-lasting, using in home
DME - CORRECT ANSWER cane, brace, commode chair, crutches, hospital bed, wheelchair
Continuum of Care - CORRECT ANSWER 5stages: wellbeing, risk factors, clinical s/s of ds, tx for DX, outcome/recovery
Palliative care program - CORRECT ANSWER constant review of pt needs and tx, while noting their religious beliefs, cultures & values
Risk Management Process - CORRECT ANSWER 1. Risk Identification
2. Risk Assessment
3. Risk Response Development
4. Risk Response Control
Change agent illness - CORRECT ANSWER any illness that affects an individual's life and physical social or psychological ways
Stages of Change - CORRECT ANSWER precontemplation, contemplation, preparation, action, maintenance, termination
Cultural Competence - CORRECT ANSWER process of providing care that's respectful and knowledgeable of cultural backgrounds
CM Accreditation phase 1 - CORRECT ANSWER 1)application
Disease Management - CORRECT ANSWER focuses on groups of patients with conditions that have high financial costs and will benefit from integrated systematic management
Case Management - CORRECT ANSWER the management of an individual patient, managing care and access to resources
CCM certification - CORRECT ANSWER Supervised 12 mons experience as FT CM, 24 mons unsupervised, 12mons supervising CM
core components of case management - CORRECT ANSWER processes and relationships, Healthcare Management, Community Resources and support, service delivery, psychological intervention, & rehabilitation case management
Justice - CORRECT ANSWER being fair or just, balance of what is best for one patient vs. what is best for larger society
Supremacy of values - CORRECT ANSWER feeling that one's own values reign supreme over all those involved
Goal of Medication Reconciliation - CORRECT ANSWER decrease med errors, omissions, duplication of drugs, drug interactions, & dosing errors
When medication reconciliation should be done? - CORRECT ANSWER patient is moved within a hospital, transfer to another facility, discharge, & at each MD visit
Main role of Case manager - CORRECT ANSWER Patient advocate
Domains of Case Management - CORRECT ANSWER care delivery/reimbursement, psychosocial concepts, quality & outcomes, rehab, legal
Healthcare reimbursement - CORRECT ANSWER one major category of knowledge necessary for case manager
Four key Functions of Case Manager - CORRECT ANSWER planner , assessor, facilitator , & advocate
Within the walls (WTW) - CORRECT ANSWER refers to activities within the hospital
Beyond the Walls (BTW) - CORRECT ANSWER refers to case management in outpatient and Community settings
Ostensible Agency - CORRECT ANSWER the relationship that exists between the case manager(agent) and a referral provider
Gag clause - CORRECT ANSWER prevents Providers from discussing uncovered(plan) treatment options with the patient
Polypharmacy - CORRECT ANSWER using multiple medications, or more than medically necessary, common in elderly
Two Physicians can serve as surrogate - CORRECT ANSWER when no legal guardian, sibling/friend/or significant other can make decisions
Hospice care requires - CORRECT ANSWER recertification of Hospice every days 60 days if patient remains alive after 6 months
Red Flag - CORRECT ANSWER indicator that the case is not routine and could benefit from a case manager: risk indicator
Medicare Advantage Plan (MAP) - CORRECT ANSWER is approved by Medicare but administered by private insurance companies
Autonomy - CORRECT ANSWER immunity from arbitrary exercise of authority, being able to undertake activities without seeking permission
HIPAA Title I - CORRECT ANSWER Ability to Transport Group Health plans w/ life events, divorce job loss, & pregnancy
HIPAA Title II - CORRECT ANSWER requires written consent and permission from the patient to share information
HIPAA Title III - CORRECT ANSWER standardized is the amount that may be saved per person in pre-tax HSA
HIPAA Title IV - CORRECT ANSWER specifies conditions for Group Health Plans regarding coverage of persons with pre-existing conditions
HIPAA Title V - CORRECT ANSWER Revenue offsets governing tax deductions for employers
Risk stratification - CORRECT ANSWER a tool for identifying and predicting which patients are high risk
I-QOL - CORRECT ANSWER a self-report instrument containing 22 items covering 3 domains of quality of life
Cost-effectiveness analysis - CORRECT ANSWER measures the effectiveness of an intervention rather than monetary savings
Palliative care is - CORRECT ANSWER care that provides comfort rather than curative treatment
Birthday rule - CORRECT ANSWER health plan uses the parent whose birthday is 1st to determine child's primary and secondary insurance policy
Indemnity Plan - CORRECT ANSWER pays predetermined payment for loss or damage rather than health care service
Outlier payment - CORRECT ANSWER payment due to unusual variation in the type or amount of medically necessary care
Hard savings - CORRECT ANSWER are avoided costs that can be measured
Handoffs - CORRECT ANSWER involves three types of transfers from one provider to another, one setting to another, or one level of care to another
COBRA - CORRECT ANSWER requires employers allow eligible employees, their spouses & dependents to maintain health insurance after loss of employment
Geriatric depression scale (GDS) - CORRECT ANSWER a 30 item self-report assessment used to identify depression in the elderly
SF 36 - CORRECT ANSWER Short-Form Health Survey that measures adult patient care outcomes
LEAN approach (quality improvement technique) - CORRECT ANSWER focused on what's valuable to customers, pt, payers, providers, regulatory bodies
Neuropsychologist - CORRECT ANSWER a psychologist who studies how dysfunctions of the brain affect behaviors
Aggregate Limits - CORRECT ANSWER limits the amount that can be paid in a policy period/year, form of stop-loss
Prospective Payment System (PPS) - CORRECT ANSWER Medicare reimbursement fixed payment based upon DX & standard function assessment
Medicare benefit period - CORRECT ANSWER begins on admission, ends 60 days after discharge from inpatient status
60% rule for Inpatient rehab facilities (IRF) - CORRECT ANSWER helps define IRF by requiring 60% of emissions have one of 13 qualifying medical conditions
unskilled - CORRECT ANSWER a worker that has not been trained or educated to do a specific type of job
Skilled workers - CORRECT ANSWER workers specialized at a specific task, credentials
indemnity plan - CORRECT ANSWER No INN/ONN, NO PCP, mbr pays deductible, no referrals needed
Indemnity payments - CORRECT ANSWER Monies paid as wage replacement for injured worker medically unfit to work .
Reserves - CORRECT ANSWER sum of money insurance company or self-insured funds set aside to pay claims cost
mental retardation - CORRECT ANSWER subaverage intellectual functioning during developmental period
Predictive model - CORRECT ANSWER process used by Managed care organizations to identify target high costs/expenditures and services
Outcome and Assessment Information Set (OASIS) - CORRECT ANSWER contains data items developed for measuring patient outcomes for the purpose of performance Improvement in home healthcare, required for all Medicaid and Medicare beneficiaries
Pooling risk - CORRECT ANSWER the grouping of high risk beneficiaries
critical pathways - CORRECT ANSWER Are healthcare provider documents that detail the main elements of day to day care activities necessary for a typical patient with a specific diagnosis
chronic care model - CORRECT ANSWER created to address deficiencies in chronic care, the Aging population and patients with chronic conditions. Can be applied to many chronic conditions in many healthcare settings
Case finding in case management essential activities - CORRECT ANSWER involves 1. dentification through referrals, 2. is diagnosis driven, 2. high-dollar referrals, 3) and repeated service requests
Key component of Case Managers job - CORRECT ANSWER follow-up and monitoring
Injured Workers - CORRECT ANSWER can change provider one time without prior approval from insurance company
Contemplation stage - CORRECT ANSWER getting ready to change possibly within 6 months
Precontemplation - CORRECT ANSWER Not intending to change behavior.
Change theory (Kurt Lewin) - CORRECT ANSWER 1 precontemplation, 2 contemplation, 3 preparation, 4 Action , 5 maintenance
Milliman care guidelines - CORRECT ANSWER considered general recovery guidelines
Hospital length of stay - CORRECT ANSWER calculated in days, for newborn begins at the time of the delivery or last time of delivery in the event of multiple births. if the delivery occurs outside ohospital begins at time mother or newborn is admitted in hospital
Transitional Care - CORRECT ANSWER the actions to assure coordination and continuity of care as patient transfer between different locations or different locations within same facility
transitions of care - CORRECT ANSWER refers to the movement of patients between locations Healthcare Providers or different levels of care within same facility. Narrow subset of the broader concept of Transitional Care
Persons vulnerable for pitfalls in transitions of care - CORRECT ANSWER non English-speaking, different cultural backgrounds, children with special needs, frail elderly person, cognitive impairments, complex conditions, disabilities, low-income
continuum of care - CORRECT ANSWER 1. well-being/independence, 2. risks factors/behaviors, 3. medical problem, 4)treatment ,5)outcome
Lions club - CORRECT ANSWER vision resource, and disabilitie, diabetic prevention and treatment
Rotary International - CORRECT ANSWER first focuses on six areas for grants:, two focus on Health disease and prevention( HIV/AIDs) maternal and child health.
Knights of Columbus - CORRECT ANSWER provides funding for charitable endeavours with a focus on disabilities
Hospice - CORRECT ANSWER MedicareA covers two 90day & unlimited 60day benefit periods, with physician revert every 60days
Covered by Medicare Part B - CORRECT ANSWER DME, 80% covered if prescribing physician and supplier are Medicare enrollees [Show Less]