CCM exam prep - all topics(Completed)study guide graded A+

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. 00:46 01:33 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: Non-Federal governmental plans that have 100 or fewer employees; Small private employers that have 50 or fewer employees; Group health plans and health insurance issuers that are exempt from MHPAEA based on their increased cost (except as noted below). Plans and issuers that make changes to comply with MHPAEA and incur an increased cost of at least 2% in the first year that MHPAEA applies to the plan or coverage or at least one percent in any subsequent plan year may claim an exemption from MHPAEA based on their increased cost. If such a cost is incurred, the plan or coverage is exempt from MHPAEA requirements for the plan or policy year following the year the cost was incurred. These exemptions last one year. After that, the plan or coverage is required to comply again; however, if the plan or coverage incurs an increased cost of at least 1% in that plan or policy year, the plan or coverage could claim the exemption for the following plan or policy year; Large, self-funded non-Federal governmental employers that opt-out of the requirements of MHPAEA. hard savings Examples of "hard" savings are directly linked to Case Management. Examples would be reduction in payer denials or decrease in avoidable days. soft savings Examples of "soft" savings are indirectly linked to Case Management such as lower readmission rates or lower post-op complication rates. These can be converted into dollars. 1987 Nursing Home Reform Act The basic objective of the Nursing Home Reform Act is to ensure that residents of nursing homes receive quality care that will result in their achieving or maintaining their "highest practicable" physical, mental, and psychosocial well-being. To secure quality care in nursing homes, the Nursing Home Reform Act requires the provision of certain services to each resident and establishes a Residents' Bill of Rights. CARF Commission on Accreditation of Rehabilitation Facilities Wickline v. The State of California the point of this litigation is that a physician/surgeon is still responsible for negligently discharging a patient even if the financial benefits related to the hospital stay have been exhausted. Wickline also seems to suggest that a physician can be negligent for not acting more aggressively as a patient's advocate with third-party payers ADA reasonable accommodations -Making existing facilities used by employees readily accessible to and usable by persons with disabilities. -Job restructuring, modifying work schedules, reassignment to a vacant position; -Acquiring or modifying equipment or devices, adjusting or modifying examinations, training materials, or policies, and providing qualified readers or interpreters. The Individuals with Disabilities Education Act (IDEA) Public Law 94-142 - a law ensuring services to children with disabilities throughout the nation. IDEA governs how states and public agencies provide early intervention, special education and related services to more than 6.5 million eligible infants, toddlers, children and youth with disabilities. Abandonment termination of a professional relationship without reasonable notice to the patient and without an opportunity for the patient to acquire alternative care or services thereby resulting in injury to the patient. Agency relationship between two or more persons by which one consents that the other (the agent) shall act on his or her behalf. Legal obligations to: 1. use care and skill 2. act in good faith 3. staying within the limits of authority 4. obeying the principal and carrying out all reasonable instructions 5. advancing the interests of the principals 6. acting solely on the principal's benefit. Implies a conflict of interest between the case manager and the employer and the professional duties to the patient. Apparent authority (ostensible agency): When a principal has taken such actions that would indicate to third parties that someone is his or her agent, the principal is held to have given "apparent authority" to the agent. The principal is held responsible for the agent's action Bad Faith attempt to mislead or decieve another or neglect refusal to fulfill some duty or some contractual obligation. Implies a conscious of wrong doing. Example: denying claim to save money. Three Components of bad faith claims denials 1. absence of a reasonable basis for denial of benefits. 2. the insurers or agent's knowledge or reckless disregard of the lack of reasonable basis for denying a claim. 3. misfeasance or maladministration in processing of claims for benefits. Bill of particulars Amplification of a legal complaint that supplies more information and detail, thereby giving the defendant a more specific picture of the claims against him. Breach of confidentiality failure of fiduciary duty. Refusal to hold secret a priviledged communication entrusted by one party to another. Claim request for payment from an insurance company. Or a report by the insured provider of care to the insurance company based on notification from the patient or the patient's attorney of an event out of which malpractice has been alleged. Comparative negligence A method of measuring negiligence among participants in a suit (defense and plaintiff) in terms of percentages of culpability. Damages are then diminished in proportion to the amount of negligence attributable to the complaining party. Complaint document by which the plaintiff gives the court and the defendant notice of the transactions, occurrences, or series of transactions or occurences intended to be proved and the material elements of each cause of action or defense. Corporate negligence legal ground of a managed care liability based on the corporate activity of the managed care organization itself rather than on the care related activities of participating healthcare professionals. Examples: Negligent credentialing and negligent supervision . Corporate practice of medicine Legal doctrine that prohibits corporations from engaging in the practice of medicine. Corporates who recognize this doctrine cannot employ physicians. Damages Monetary compensation awarded for acts of tort for both tangible (medical expenses, loss wages) and intangible (pain and suffering) Discovery Ascertainment of what is not previously known. All evidence that is material and necessary in the prosecution or defense of action is produced and exchanged by the parties or as ordered by the court. Event (incident) a situation that is reported by the insured provider to his or her insurance company which may lead to a formal claim or malpractice suit. Examination before trial obtaining information by sworn oral testimony False Claims Act Federal penalties for those who knowingly present false claim or against the government. It is illegal to present a false or fraudulent claim upon or against the US. HOld harmless provision Contract between insurer and provider of services that specifies that the providers assumes liability for covered services even if the managed care organization becomes insolvent. Inherent risk a complication that is commonly associated with a treatment and is not due to negiligence of the provider of the treatment. Invasion of privacy wrongful intrusion into one's private activities which would cause harm to the patient Liability debt, responsibility, obligation Liability, joint Obligation as a group or as a whole and all its individual members. A party that has been harmed can sue the group as a whole or by its individuals but the suer cannot get more compensation by suing individually than by suing as a whole. Liability limits Restriction or upper boundary on the amount of money on insurance company will pay in order to satisfy a claim against an insured. A calim for a sum beond this limit is not protected bt teh insurance policy and is that the responsibility of the defendant Liable bound by law or fairness responsible and accountable Malpractice Act of negligence, 1. negligence: a deviation from the approved and accepted standards of care. 2. injury which damage is to the patient as result of the negligence. Most favored nation Clause provider is obligated to render products or services to the purchaser at the same rate as his most favored customer Negligence Failure to use the degree of care . Ommision and commission. Negligent credentialing When a organization does not exercise care when investigating a provider's credentials. Example when an organization selects a provider who negligently injures a patient, has a history of doing so or is found not to have the appropriate training , experience, skill or licensure to care for the patient. Negligent Referral Referring a patient to a provider who does not posses the right credentials, skills, licensure or who has been known to be negligent in the past. Ombudsman a person who investigates customer complaints against their employer. Ostensible agency A principal gives a third party reason to believe another person is ‎his/her agent; other person is unaware of the appointment.‎ In these cases the "principal" is responsible for the acts of the agent. Principal gives apparent authority to the agent and will be liable for his acts Out of Court setllement Agreement or transaction between two litigants to settle the matter privately and not in court Privileged communications Information that is disclosed by a patient to a provider that remains confidential unless patient waives his privilege. Disclosure of such information may constitute as an invasion of privacy which is an actionable tort Res ipsa loquitor (things speak for itself). Mere proof that an occurence took place is sufficient. Injury was case by the defendants exclusive control and that the accident was one that ordinarily doesn't happen in the absense of negiligence. Example: when a patient is found to hav an surgical instrument left in his abdomen. Respondeat Superior Let the master answer: master is liable for acts of his servant. Statutue of limitations period of time which a plaintiff can bring a lawsuit after an incident has occurred. Subpoena A judicial process requiring a witness