CCM exam prep - all topics 2022 with complete
solution
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.
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
solution
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.
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
