CCM Multiple Choice Exam 17 Questions with Verified Answers
All of the following are true regarding coordination of benefits (COB) except:
A) COB
... [Show More] prevents double payment for services when a subscriber has health insurance coverage from two or more sources.
B) COB is voluntary.
C) COB determines which insurer pays first when the insured is covered under more than one health insurance policy.
D) COB coordinates workers' compensation with health insurance coverage. - CORRECT ANSWER Answer: D) COB coordinates workers' compensation with health insurance coverage.
Rationale: COB does not coordinate benefits with workers compensation. COB is a voluntary program that prevents double payment for services when the subscriber has health insurance from more than one source. COB has rules to determine which insurer pays first.
Utilization management reviews services to ensure that:
A) each line item on a submitted claim is an appropriate charge
B) they are medically necessary, provided in the most appropriate care setting, and at or above quality standards.
C) appropriate discharge planning is performed.
D) they are ordered by a physician, provided in the most appropriate care setting, and exceed quality standards. - CORRECT ANSWER Answer: B) they are medically necessary, provided in the most appropriate care setting, and at or above quality standards.
Resource: CCMC Glossary of Terms
Rationale: Utilization Management: Review of services to ensure that they are medically necessary, provided in the most appropriate care setting, and at or above quality standards.
The case managers role when working with clients with substance abuse is to:
A) Motivate the client to change.
B) Support the treatment plan and assist in finding resources.
C) Counsel the client.
D) Monitor for substance use. - CORRECT ANSWER Answer: B) Support the treatment plan and assist in finding resources.
To meet the criteria of medical necessity all of the following should be present except:
A) It is reasonable
B) It is based on evidence-based standards of care
C) It is appropriate
D) It is custodial - CORRECT ANSWER Answer: D) It is custodial
The Ambulatory Payment Classification System (APC) is used to determine payment rates for which one of the following under Medicare?
A) Ambulatory surgery
B) Outpatient rehabilitation and ambulatory surgery
C) ER, hospital-based clinic, observation, and ambulatory surgery
D) Physician office visits - CORRECT ANSWER Answer: C) ER, hospital-based clinic, observation and ambulatory surgery
Rationale: The Ambulatory Payment Classification System (APC) is Medicare's prospective payment system for the hospital-based clinic, ER, observation, and ambulatory surgery encounter.
Which would be most appropriate for a 48-year-old nurse who has a broken leg as the result of a work-related injury?
A) Work hardening
B) Work adjustment
C) Transitional Work Duty
D) Temporary Total Disability - CORRECT ANSWER Answer: C) Transitional Work Duty
Rationale: Transitional work duty (TWD) allow an injured employee to return to work. The employer will create a temporary position which conforms to the restrictions put in place by the employee's treating physician.
Which of the following is not used by case managers to foster wellness and autonomy?
A) Advocacy
B) Education
C) Coercion
D) Communication - CORRECT ANSWER Answer: C) Coercion
http://ccmcertification.org/.../definition-and-philosophy-cas...
CCMC's Philosophy of Case Management
Your client is considering a viatical settlement to help cover medical expenses. All of the following are true about viatical settlements except:
A) The patient will be required by law to continue making the premium on the policy.
B) The money received from a viatical settlement is usually free from federal income tax.
C) The money received from a viatical settlement may impact eligibility for Medicaid.
D) There are no restrictions on how the money received from a viatical settlement can be used. - CORRECT ANSWER Answer: A) The patient will be required by law to continue making the premium on the policy
Rationale: The purchasing party becomes the beneficiary and takes responsibility for paying the premium. The money received from a viatical settlement is usually free from federal income tax but may impact eligibility for Medicaid. There are no restrictions on how the money received from a viatical settlement can be used.
All of the following are true of an accelerated death benefit except:
A) It can be a rider on a life insurance policy
B) There are restrictions on how the money can be used
C) It is part of the Medicare Hospice Benefit
D) It allows the insured person to use some of the policy's benefit prior to dying - CORRECT ANSWER Answer: C) It is part of the Medicare Hospice Benefit
Rationale: Some life insurance policies have an accelerated death benefit (ADB) rider, allowing the insured person to use some of the policy's benefit prior to dying. The ADB is deducted from the amount the beneficiaries receive at death. There are restrictions on how the one can be used; generally, it can be used for the long-term care and medical expenses.
Under Medicare, the Case Mix Group (CMG) is used to determine payment rates for which one of the following?
A) Skilled Nursing Facility (SNF)
B) Inpatient rehabilitation
C) Acute care hospitals
D) Home health agencies - CORRECT ANSWER Answer: B) Inpatient rehabilitation
Rationale: Case Mix Group (CMG) is used to establish payment rates for skilled nursing facilities and determine reimbursement. The patient is assessed using the Patient Assessment Instrument (IRF-PAI). The IRF- PAI classifies patients into groups based on clinical characteristics and expected resource needs. PAI determines the patient's CMG. The CMG determines the payment rate per stay.
Health coaching is for:
A) Clients who suffer from a chronic disease.
B) Clients who want to prevent disease.
C) Caregivers of patients.
D) Medical professionals - CORRECT ANSWER Answer: A) Clients who suffer from a chronic disease.
Rationale: Health coaching is secondary prevention. Clients who
already have a chronic disease can benefit from learning to manage the disease.
If the case manager discovers that the client's cultural beliefs are very different from the case managers, the case manager should:
A) Respect the client's beliefs, even though she may not agree with them.
B) Close the client to case management.
C) Transfer the client's case to another case manager with similar cultural beliefs.
D) Confront the client, informing them that their beliefs are incorrect. - CORRECT ANSWER Answer: A) Respect the client's beliefs, even though she may not agree with them.
Rationale: The client's cultural beliefs may be very different from the case manager's. This can influence how a case manager views her clients. The case manager must respect the client's beliefs, even though she may not agree with them. It can be helpful to acknowledge the cultural differences between the client and reassure the client that the case manager's job is to educate him and support his decisions.
The type of health insurance that uses primary care physicians as "Gatekeepers" requiring referrals for specialty treatments is a(n):
A) PPO
B) HMO
C) Indemnity plan
D) Cost-sharing plan - CORRECT ANSWER Answer: B) HMO
Rationale: HMOs often have a Primary Care Provider (PCP) who acts as a gatekeeper. The gatekeeper's role is to provide medical and preventative care and to coordinate patient care outside of his or her scope of practice.
A school teacher retires after 20 years of service with retiree health insurance benefits. The following year she accepts a full-time position with a library. When she is hospitalized, which health insurance policy will pay first?
A) Her husband's health insurance policy
B) Her retiree health insurance policy
C) Her current employer's health insurance policy
D) Her current employer's health insurance policy and her retiree health insurance policy will split the cost 50/50 - CORRECT ANSWER Answer: C) Her current employer's health insurance policy
Rationale: The COB rules state the insurance plan that covers an active employee is primary over the plan that covers a laid-off or retired employee.
A 68-year-old wheelchair bound patient, who resides in an assisted living facility arrives for his routine yearly exam. He is accompanied by his caregiver, who he appears fearful of. He is unkempt, dehydrated, thin and frail appearing. He avoids eye contact when answering questions. The appropriate action for the case manager is to:
A) Notify state protective services or other appropriate state authorities.
B) Confront the caregiver.
C) Notify the owner of the assisted living facility.
D) Notify the attending physician, it is his responsibility to take appropriate action. - CORRECT ANSWER Answer: A) Notify state protective services or other appropriate state authorities.
Rationale: Case managers are mandated report of abuse or neglect. If abuse or neglect is suspected, they must notify Adult Protective Services or other appropriate state authorities. Other steps may need to be taken such as transferring the patient to another assisted living
facility, notifying the facility owner or physician. Confronting the caregiver may place the patient in jeopardy.
Workers' compensation pays for all of the following except:
A) Benefits to survivors of workers who die of work-related causes
B) Rehabilitation and training for workers who are unable to return to pre-injury careers
C) Medical care for work-related injuries
D) Legal fees - CORRECT ANSWER 16. Answer: D) Legal fees
Rationale: After a work injury a worker who is approved for workers' comp benefits can generally expect to receive:
• Payment for medical treatment and expenses.
• Payment for time off work for recovery.
• Payment for any permanent impairment.
• Vocational rehabilitation services if the worker is unable to return to a pre-injury career.
• Payment of benefits in the event of death. A deceased workers' dependents are entitled to burial expenses and a lump-sum payment in most states.
The Instrumental Activities of Daily Living (IADL) tool includes assessment of all of the following except:
A) Shopping
B) Ability to use telephone
C) Ability to navigate stairs
D) Ability to handle finances - CORRECT ANSWER Answer: C) Ability to navigate stairs
Rationale: Instrumental Activities of Daily Living (IADL) tool assesses:
• Ability to use a telephone
• Shopping
• Food Preparation
• Housekeeping
• Laundry
• Mode of Transportation
• Responsibility for own Medications
• Ability to handle finances [Show Less]