ACMA EXAM STUDY MATERIAL QUESTIONS WITH
CORRECT ANSWERS ALREADY PASSED!!
UR committee
· Consists of >2 practitioners, > 2 must be doctors of medicine/osteopathy.
· Must be 1: Institution staff committee; group outside institution; established by local
med society & some/all of local hospitals; established manner CMS approved
· May not be conducted by person w/direct financial interest in hospital or prof involved
in care of pt who's case is under review
utilization review
Hospitals must have, provides review of services furnished by institution/mbrs of med
staff to pts entitled to benefits under M/M programs.
scope & freq of UR
Plan must provide review for M/M w/respect to med necessity of:
· Admissions; duration of stay; professional services provided (including
drugs/biologicals)
· Review of admissions may be performed before, at or after admission
· Reviews may be conducted on sample basis
Hospitals paid for IP services under prospective pymt system must conduct
review as for
· Duration of stays: only reasonably assume to be outlier based on extended LOS &
· Professional services: only reasonably assume to be outlier based on extraordinarily
high cost
Determination regarding admissions/cont stays
·Made by 1 mbr of committee if provider liable for pt care concur w/determination or fail
to present views when given chance & must be made by >2 mbrs of committee in all
other cases
·Before decision made on admission/cont stay is not med necessary; committee consult
providers responsible for pt care, giving change to present views
· If committee decides admission/cont stay is not med necessary, written notice to be
given w/in 2 d after decision to hospital/pt/providers responsible for care.
Extended stay review: hospital not paid under prospective pymt system
committee must make periodic review (per UR plan) of ea current IP receiving hospital
services in cont of extend duration. Scheduling periodic review may: Be same for all
cases, differ for diff class of cases.
Extended stay review: hospital paid under prospective pymt system
committee must review all cases reasonably assumed to be outlier cases b/c extended
LOS exceeds threshold criteria for dx. Hospital not req to review extended stay that
does not exceed outlier threshold for dx. Periodic review w/in 7d after day req in UR
plan
Review of professional services
committee must review professional serviced provided, determine med necessity & to
promote most efficient use of avail health facilities/services.
Conditions of Participation (CoP)
, hospitals must have effective d/c planning process, focus on pt's goals/tx preferences &
include pt/Cg as partners in d/c planning for post-d/c care. Ensure effective transition
from hospital to post-d/c care, < factors leading to avoidable readmissions
D/c planning process
Must ID, early in hospitalization, pts likely to suffer adverse health conseq & d/c in
absence of adequate d/c planning & must provide d/c planning eval for pts ID & from
req of pt/pt rep/pt physician
D/C planning eval must
Be made on timely basis to ensure appro arrangements for post-hospital care are made
before d/c & avoid unnecessary delays in d/c
·Include: eval of pts likely need for approp post-hospital services (hospice, post-d/c
extended care, HH, non-HC, community care providers) & decision of availability of
appropriate services of pt's access to those services.
· Be included in pt's med record to use in establishing d/c plan & results of eval
discussed w/pt
· Upon request, hospital must arrange for develop/initial implementation of d/c plan for
pt
· Be developed by/under supervision of RN/SW or appropriately qualified personnel
· Req reg re-eval of condition, ID changes that req revision to d/c plan. Plan updated to
reflect
· Be assessed by hospital routinely; assess includes: ongoing/periodic review of rep
sample of d/c plan; readmissions w/in 30d of prev admission; ensure plan responsive to
post-d/c needs
· Hospital must assist pt/fam in selecting post-acute care provider by using
HHA/SNF/IRF/LTCH data on quality measures/resource use measures. Hospital to
ensure post-acute care data is relevant/applicable to pt's goals of care & tx preferences
D/C of pt & provision/transmission of pt's needed med info
hospital must d/c pt, transfer/refer as needed, w/all necessary med info r/t current
course of illness/tx, post-d/c goals, tx prefs, at time of d/c, to appropriate post-acute
service/provider/supplier/facility/agencies others responsible for f/u or ancillary care.
Requirements r/t post-acute care
pt d/c home & referred for HHA or transferred to SNF for post-hospital extended care, or
transferred to IRF/LTCH for specialized hospital services
Requirements r/t post-acute care req apply
Hospital must include in d/c plan, list of HHA/SNF/IRF/ LTCH avail/participating in
Medicare program & that serve geographic area (HHA) which pt resides, or for
SNF/IRF/LTCH in area requested by pt. HHAs must request to be listed by hospital as
avail; list must only be presented to pt for whom HH post-hospital extended care
services, SNF/IRF/LTCH services are indicated & appropriate as determined by d/c
planning eval. Pt enrolled in managed care orgs, hospital must make pt aware of need
to verify w/org which providers/certified suppliers are in network.
D/C plan must ID
HHA/SNF which pt is referred, in which hospital has disclosable financial interest, & any
HHA/SNF that has disclosable financial interest in hospital under Medicare.
Hospital must inform pt
CORRECT ANSWERS ALREADY PASSED!!
UR committee
· Consists of >2 practitioners, > 2 must be doctors of medicine/osteopathy.
· Must be 1: Institution staff committee; group outside institution; established by local
med society & some/all of local hospitals; established manner CMS approved
· May not be conducted by person w/direct financial interest in hospital or prof involved
in care of pt who's case is under review
utilization review
Hospitals must have, provides review of services furnished by institution/mbrs of med
staff to pts entitled to benefits under M/M programs.
scope & freq of UR
Plan must provide review for M/M w/respect to med necessity of:
· Admissions; duration of stay; professional services provided (including
drugs/biologicals)
· Review of admissions may be performed before, at or after admission
· Reviews may be conducted on sample basis
Hospitals paid for IP services under prospective pymt system must conduct
review as for
· Duration of stays: only reasonably assume to be outlier based on extended LOS &
· Professional services: only reasonably assume to be outlier based on extraordinarily
high cost
Determination regarding admissions/cont stays
·Made by 1 mbr of committee if provider liable for pt care concur w/determination or fail
to present views when given chance & must be made by >2 mbrs of committee in all
other cases
·Before decision made on admission/cont stay is not med necessary; committee consult
providers responsible for pt care, giving change to present views
· If committee decides admission/cont stay is not med necessary, written notice to be
given w/in 2 d after decision to hospital/pt/providers responsible for care.
Extended stay review: hospital not paid under prospective pymt system
committee must make periodic review (per UR plan) of ea current IP receiving hospital
services in cont of extend duration. Scheduling periodic review may: Be same for all
cases, differ for diff class of cases.
Extended stay review: hospital paid under prospective pymt system
committee must review all cases reasonably assumed to be outlier cases b/c extended
LOS exceeds threshold criteria for dx. Hospital not req to review extended stay that
does not exceed outlier threshold for dx. Periodic review w/in 7d after day req in UR
plan
Review of professional services
committee must review professional serviced provided, determine med necessity & to
promote most efficient use of avail health facilities/services.
Conditions of Participation (CoP)
, hospitals must have effective d/c planning process, focus on pt's goals/tx preferences &
include pt/Cg as partners in d/c planning for post-d/c care. Ensure effective transition
from hospital to post-d/c care, < factors leading to avoidable readmissions
D/c planning process
Must ID, early in hospitalization, pts likely to suffer adverse health conseq & d/c in
absence of adequate d/c planning & must provide d/c planning eval for pts ID & from
req of pt/pt rep/pt physician
D/C planning eval must
Be made on timely basis to ensure appro arrangements for post-hospital care are made
before d/c & avoid unnecessary delays in d/c
·Include: eval of pts likely need for approp post-hospital services (hospice, post-d/c
extended care, HH, non-HC, community care providers) & decision of availability of
appropriate services of pt's access to those services.
· Be included in pt's med record to use in establishing d/c plan & results of eval
discussed w/pt
· Upon request, hospital must arrange for develop/initial implementation of d/c plan for
pt
· Be developed by/under supervision of RN/SW or appropriately qualified personnel
· Req reg re-eval of condition, ID changes that req revision to d/c plan. Plan updated to
reflect
· Be assessed by hospital routinely; assess includes: ongoing/periodic review of rep
sample of d/c plan; readmissions w/in 30d of prev admission; ensure plan responsive to
post-d/c needs
· Hospital must assist pt/fam in selecting post-acute care provider by using
HHA/SNF/IRF/LTCH data on quality measures/resource use measures. Hospital to
ensure post-acute care data is relevant/applicable to pt's goals of care & tx preferences
D/C of pt & provision/transmission of pt's needed med info
hospital must d/c pt, transfer/refer as needed, w/all necessary med info r/t current
course of illness/tx, post-d/c goals, tx prefs, at time of d/c, to appropriate post-acute
service/provider/supplier/facility/agencies others responsible for f/u or ancillary care.
Requirements r/t post-acute care
pt d/c home & referred for HHA or transferred to SNF for post-hospital extended care, or
transferred to IRF/LTCH for specialized hospital services
Requirements r/t post-acute care req apply
Hospital must include in d/c plan, list of HHA/SNF/IRF/ LTCH avail/participating in
Medicare program & that serve geographic area (HHA) which pt resides, or for
SNF/IRF/LTCH in area requested by pt. HHAs must request to be listed by hospital as
avail; list must only be presented to pt for whom HH post-hospital extended care
services, SNF/IRF/LTCH services are indicated & appropriate as determined by d/c
planning eval. Pt enrolled in managed care orgs, hospital must make pt aware of need
to verify w/org which providers/certified suppliers are in network.
D/C plan must ID
HHA/SNF which pt is referred, in which hospital has disclosable financial interest, & any
HHA/SNF that has disclosable financial interest in hospital under Medicare.
Hospital must inform pt
