General CM questions from my courses
A key element of success in implementation of a case management model is: a. Education b. Research c. Process d. Outcomes
A
A predominant role of case managers in a workers' compensation setting is: a. Rehabilitation b. Gatekeeping c. Transitional planning d. Health maintenance
A
The process of moving from an undesirable state to a desirable state is: a. Problem solving b. Conflict resolution c. Diagnostic reasoning d. Variance analysis
A
Case management is a process and outcomes model designed to: a. Manage resources and maintain quality care b. Decrease inpatient stays and find alternate care c. Identify research topics and project costs d. Develop partnerships and increase caregivers satisfaction
A (Feedback: Survival Guide, Chapter 1)
A range of medical, nursing and social services and treatments, offered in a variety of settings that provide services most appropriate to the level of care required is known as: a. Case management b. Health care system c. Quality management d. Continuum of care
B
Case managers assist patients by A) Intervening with discharges B) Assessing their needs C) Facilitating early release from patient care D) controlling care received
B
The result and consequence of a healthcare process is: a. Reimbursement b. An outcome c. Case management d. Authorization
B
The structures, organization and services designed to deliver professional health and wellness services are defined as: A) an HMO health plan B) Health care system C) case management D) a collective system
B
The system in which consumers paid for each health care service is known as: (Points : 1) a. Point of service b. Fee for service c. Traditional indemnity d. Risk reduction
B
One professional who is effective in outpatient settings, where patient needs are related to financial and social issues, more than clinical concerns is: a. Registered nurse b. Social worker c. Elder care specialist d. Clinical nurse specialist
B (Feedback: Survival Guide, Chapter 3)
A third party administrators/administration (TPA) group: a. Pays claims based on outcomes b. Handles claim functions such as UR and claim payments c. Reviews all claims based upon DRG's d. Reviews all claims for predictive modeling
B (Feedback: CMSA Core Curriculum)
The Health Information Portability and Accountability Act of 1996 (HIPAA): a. Can increase waiting periods for insurance payment b. Gives patients the right to obtain their own records c. Increases the release of information to others d. Provides privacy rules that hinder patient rights
B (Feedback: CMSA Core Curriculum)
The history of case management, case management models and systems of reimbursement are considered: a. Methods of case management model development b. Core content for case management curricula c. Strategies for outcomes management d. Options to develop interdependence
B (Feedback: Nursing Case Management, Chapter 8)
A strategy for understanding internal processes and performance levels is/are: a. Databases b. Benchmarking c. Critical pathways d. Milestones
B (Feedback: Survival Guide, Chapter 1)
The term "continuum of care" was first applied in: a. Elder care management b. Behavioral health case management c. Hospital based case management d. Utilization review
B (Feedback: Survival Guide, Chapter 1)
A form of personal liberty of action in which the patient holds the right and freedom to select treatment is known as: a. Justice b. Veracity c. Autonomy d. Beneficence
C
A process of give and take exchange among persons that is aimed at reaching agreements is: a. Intervention b. Persuasion c. Negotiation d. Adaptation
C
A process of joint decision making among interdependent parties, involving joint ownership of decisions and collective responsibility for outcome is: A) Group decision making B) Conflict Resolution C) Collaboration D) Research
C
A state licensed entity that agrees by contract to provide medical services on a prepaid basis is a/an: a. MCO b. TPA c. HMO d. PPO
C
One of the forces leading acute care settings toward adoption of case management models was: a. Population increase b. Physician practice groups c. Prospective payment system d. Decline in employer insurance
C
Predominant skills required for case managers include: a. Care giving and documentation b. Obtaining authorization and certification c. Collaboration and decision-making d. Creating a plan of care and utilization review
C
The case management approach represents a response to: A) a need for organization of health care only B) Eliminating patient education programs C) Planning for needed community resources D) Identification of high cost care
C
The effectiveness of a case management program may be demonstrated by: a. Insurance company acceptance b. Case manager independence c. Appropriate resource use d. Guaranteed reimbursement
C
The process of communication with case managers in an MCO to obtain authorization for services is: a. Pre-certification b. Transitional planning c. Concurrent review d. Demand management
C
A written plan that identifies critical incidents that occur at set times to achieve specific outcomes is a/an: a. Medical records b. OASIS c. Critical pathway d. Multidisciplinary plan
C (Feedback: Leadership and Nursing Care Management, Chapter 21)
A system of coordinated health care interventions for populations with chronic conditions is: a. Risk management b. Utilization management c. Disease management d. Predictive modeling
C (Feedback: CMSA Core Curriculum)
An organization that provides for coverage of designated health services needed by plan members for a fixed prepaid premium is: a. A PPO b. An EPO c. An HMO d. An IDS
C (Feedback: CMSA Core Curriculum)
The National Committee for Quality Insurance (NCQA) is an organization of health care quality management specialists that: a. Controls health care costs b. Promotes health plan stability c. Offers an accreditation program for managed health care plans d. Reviews cases after denial
C (Feedback: CMSA Core Curriculum)
A standardized program for evaluating health care organizations to ensure a specified level of quality is: a. Certification b. Quality assurance c. Accreditation d. Licensure
C (Feedback: Survival Guide, Glossary)
A combination state/ federal progra, to provide access to health care for the poor is: A) Medicare B) Med PAC C) SSDI D) Medicaid
D
Case Management practice may be found A) In the hospital setting only B) In all physican practices C) Throughout all private insurances D) Throughout healthcaee settings
D
Sophisticated case management plans are known as: A) critical pathways B) Benchmarking C) Documentation records D) Multidisciplinary action plans (MAPS)
D
patient classification method that provides a means of relating the type of patient to the associated costs is: (Points : 1) a. DSM - IV b. CPT c. ICD - 9 d. DRG
D
Access to health care in the United States: a. Is influenced by having or not having insurance b. Is shifting from acute care to alternate settings c. Varies by race d. All of the above
D (Feedback: Leadership and Nursing Care Management, Chapter 14)
A predetermined dollar amount for which a member of a health plan is responsible for each time the service is rendered is known as: a. Co-insurance b. Capitation c. Deductible d. Co-pay
D (Feedback: CMSA Core Curriculum)
Any medical condition that has heightened medical, social and financial consequences is known as: a. A referral for disease management b. A case for transfer to a tertiary center c. A primary care case d. A catastrophic case
D (Feedback: CMSA Core Curriculum)
Benefits paid for bodily injury or damage to personal property is: a. Stop-loss insurance b. Medicaid c. Accident and health insurance d. Liability insurance
D (Feedback: CMSA Core Curriculum)
One concern for creative health care reimbursement is: a. The consistency of payment across plans b. The flexibility of payments for varied services c. Mandated benefits by the federal government d. The need for patient and provider education
D (Feedback: CMSA Core Curriculum)
The Centers for Medicare and Medicaid Services is conducting _________ to measure the value of case management is: a. Critical pathways analysis b. Research on targeted allocation of resources according to diagnosis c. Beneficiary surveys of provision of follow-up care over the short term d. Demonstration studies and projects
D (Feedback: Leadership and Nursing Care Management, Chapter 21)
Case management requires the use of: a. Physician direction b. A panel of providers c. HMO's and PPO's d. A team approach and elements of CQI
D (Feedback: Survival Guide, Chapter 1)
A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians is: a. Diagnostic-Related Group (DRG) b. Continuous Quality Improvement (CQI) c. Minimum Data Set (MDS) d. Current Procedural Terminology (CPT)
D (Feedback: Survival Guide, Glossary)
A step in distinguishing the roles and responsibilities of a case manager during model implementation is to: a. Distribute a job description b. Identify impact on provider c. Address role changes for other jobs d. Focus upon cost issues
A
A trend which has brought about major changes in the American health care delivery system is: a. A shift in consumer behavior b. Universal health care c. Clinical resource models d. Outcomes research
A
An association of individual independent physicians formed for the purpose of contracting with one or more managed health care organizations is a/an: a. IPA b. HMO c. PPO d. DRG
A
Because of their clinical experience and knowledge of operational systems, policies and standards of care, case managers may be called upon to serve as: a. Consultants b. Clinical experts c. Caregivers d. Risk mangers
A
Because of their clinical experience and knowledge of operational systems, policies and standards of care, case managers may be called upon to serve as: a. Consultants b. Clinical experts c. Caregivers d. Risk mangers
A
Care that is unit bases, outcome-oriented and dependent upon a designated time frame is known as: A) Managed Care B) Primary Care C) Holistic Care D) Integrated Care
A
In primary care case management, the case manager is: A) a physician B) the ulitization review team C) the discharge planner D) a nurse
A
Leadership in establishing culture is: a. Creating a vision so convincing that the team is inspired to engage and move forward b. The extent to which a person adheres to standards c. Using the authority granted in formal title to exercise control in groups d. The ability of the person to quote ethics
A
One goal of case management is to: A) Manage cost and quality B) Advocate for the insurance plan C) Obtain authorizations for care D) Demonstrate facility profit
A
Telephone triage and online advice services to reduce available hospital visits is known as: A) Demand Management B) First level reviews C) Capitation D) Referral Review
A
Community-based case management models focus on: a. The continuum of care b. Acute treatment and rehabilitation c. Managing populations d. Outpatient clinic care
A (Feedback: Survival Guide, Chapter 3)
A grouping of specific activities within a role is known as a: a. Function b. Job description c. Context d. Role
A (Feedback: CMSA Core Curriculum)
A point of service (POS) health care delivery system results in: a. The covered person choosing care providers b. Payment of the same benefit levels c. Lower premium costs d. A blend of the HMO and IDS models
A (Feedback: CMSA Core Curriculum)
Predictive modeling is the: a. Process to identify which plan members will have the highest future costs for care b. Maximum per year for which a plan member is responsible c. Assessment tool used to place a patient into a resource utilization group d. Process to link individuals to needed care
A (Feedback: CMSA Core Curriculum)
The ongoing process of gathering sufficient information from all relevant sources regarding the effectiveness of the case management plan implemented is: a. Monitoring b. Assessment c. Implementation d. Evaluation
A (Feedback: CMSA Core Curriculum)
Under the Employee Retirement Income Security Act (ERISA): a. Self-insured companies are not required to hold the same minimum benefit regulations b. Employees may choose the delivery system c. No care may be withheld d. Care provided is a negotiated package
A (Feedback: CMSA Core Curriculum)
The major components of the system that enables individuals to receive health care is: a. Health care system b. Medical education c. Managed care d. Primary care
A (Feedback: Leadership and Nursing Care Management, Chapter 14)
Data suggest that the U.S. health care system is primarily funded: a. Privately b. Self-funded c. Government d. Publicly
A (Feedback: Nursing Case Management, Chapter 21)
"Within-the-walls" case management has benefited hospitals by: A) Improving communications in the community B) Improving quality of care C) Improving doctor-patient relationships D) Increased use of resources available
B
A case management model that allows for a smooth transition from one setting to another is: A) Collaborative case management model B) Integrated case management model C) Differentiated case management model D) Community based case management model
B
Primary Case Management takes on the role of: A) Preventing hospitalizations B) Gatekeeper C) Brokerage agency D) Oversight of care
B
Refusal to comply with case management recommendations is an example of: a. Risk management b. Variance of care c. Outcomes management d. Patient rights
B
The care management approach has been developed to provide: A) Catastrophic case management B) Health planning for groups of individuals across the continuum C) Elder case management D) Health planning for those with chronic illness
B
The largest purchaser of health care in the United States is: a. The over 65 population b. Medicaid c. Persons with disabilities d. Medicare
B
A major driver of increasing health care costs is: a. Insurance b. Technology c. Pharmaceuticals d. Physicians
B (Feedback: Leadership and Nursing Care Management, Chapter 14)
Acute care case management focuses upon: a. Triage and gatekeeping b. Population risk c. Utilization review and transition planning d. Self-care management
C
Liability of managed care providers is: a. Not an issue in managed care b. Frequently identified c. A continuing issue in health care d. A problem with providers
C
One of the most widely recognized changes in the health care system was caused by: A) NCCAM B) HEDIS C) HIPAA D) COGME
C
One change that has brought case management to the forefront of health and medical care delivery systems is: a. The increase in numbers of insureds b. The increase in health maintenance services c. The increased complexity of coordinating care services d. The increase in funding for social services
C (Feedback: CMSA Core Curriculum)
The reimbursement method in which providers are paid for each service performed is: a. Risk sharing b. Capitation c. Fee for service d. Global payment
C (Feedback: CMSA Core Curriculum)
The review process applied to approve a health care provider, such as a physician as a provider of care and participant in a health care plan is: a. Certification b. Examination c. Credentialing d. Licensure
C (Feedback: CMSA Core Curriculum)
The national health insurance p rogram, for persons age 65 and older, some persons with disabilities and persons with end stage renal disease, is: a. Medicaid b. Title XIX c. Medicare d. HIPAA
C (Feedback: Leadership and Nursing Care Management, Chapter 8)
A common tool to measure functional status is: a. WRAT b. Finger tapping test c. Functional Independence Measure (FIM) d. Functional Abilities Measure (FAM)
C (Feedback: Survival Guide, Chapter 14)
In some organizations the case management model is applied to a select group of patients who: a. Are able to participate in planning b. Request case management services c. Are members of an HMO d. Meet predetermined criteria
D
A term used to refer to the manag ement of long-term health care, legal and financial services under a psychosocial model is: a. Evidence based care b. Case management c. Bench marking d. Care management
D (Feedback: CMSA Core Curriculum)
Case management originated as a community-based model: a. As a result of managed care b. In response to an aging population c. As a cost containment strategy d. In the late 1800s and early 1900s
D (Feedback: Survival Guide, Chapter 1)
The first step in problem solving is: a. Define the problem b. Gather information c. Define options d. Collaborate with the team
A
Workers' compensation insurance: a. Provides medical benefits and replacement of lost wages for those who experience injury at work b. Is funded and operated by the federal government c. Is regulated by the federal government d. Is available only in certain work venues
A (Feedback: CMSA Core Curriculum)
The most common outcome measure used in case management is: a. Length of stay b. Cost per day c. DRG's d. Denial rates
A (Feedback: Survival Guide, Chapter 14)
A choice among alternatives is known as: a. Problem solving b. Decision making c. Integration d. Group persuasion
B
A health care delivery system in which a party other than the health care giver or the patient influences the type of care delivered is: a. Care budgeting b. Managed care c. Workers' compensation d. Direct contract
B
Integrated case management models rely upon: A) patient intake B) Nursing roles attached to a physician C) Different reimbursement dependent on location D) Community based care management model
B
An insurance plan that often has a lifetime maximum benefit is: a. Workers' compensation b. Accident and health insurance c. Disability insurance d. Long-term nursing home insurance
B (Feedback: CMSA Core Curriculum)
One method used to track appropriateness of care and consumption of resources is: a. Transitional planning b. Retrospective review c. Concurrent review d. Precertification
B (Feedback: CMSA Core Curriculum)
Payer source for health care benefits m ay be classified into two groups, which are: a. Public payment and Medicare b. Commercial insurance and government payers c. Private payment and co-insurance d. Capitated plans and payer approval
B (Feedback: CMSA Core Curriculum)
The case manager role-related term of domain is defined as: a. A discrete task performed by the case manger b. An area of practice and/or knowledge c. The activities a case manager performs in his/her job d. The locale of an event
B (Feedback: CMSA Core Curriculum)
The value of case management: a. Is measured by managed care financial goals being met b. Is controversial regarding methods and measures to assess the value c. Is calculated using regression analysis d. Is measured by quality improvement indicator
B (Feedback: Leadership and Nursing Care Management, Chapter 21)
Outcomes that are directly related to a patient's health and functioning are known as: a. Clinical outcomes b. Quality outcomes c. Fiscal outcomes d. Discharge outcomes
B (Feedback: Survival Guide, Chapter 4)
An encounter-based classification system for outpatient reimbursement is: a. ICD-9 coding b. Ambulatory patient classification system (APC) c. Appropriateness of setting evaluation d. Ambulatory guide to care
B (Feedback: Survival Guide, Glossary)
.Acute care case management focuses upon: a. Triage and gate-keeping b. Population risk c. Utilization review and transition planning d. Self-care management
C
Case management is designed to: A) control costs during an inpatient stay B) prevent access to alternative care C) Ensure quality care is provided in a cost-effective manner D) Retrospectively plan care
C
One benefit of care management is: A) Improved costs in catastrophic cases B) Decreased need for patient communication C) Improved health for peopled in low-risk categories D) Decreased need for case management
C
One contributor to the rise in health care costs is: a. Prospective payment systems b. DRG's c. Technology d. Reinsurance
C (Feedback: CMSA Core Curriculum)
The process whereby an HMO and a contracted provider each accept partial responsibility for the financial costs and rewards involved in effective care for the members is known as: a. Continuum of care b. Care management c. Risk sharing d. Utilization management
C (Feedback: CMSA Core Curriculum)
Case management applications in the 1980s evolved as a result of: a. Increased influence on care by insurance companies b. Application of diagnostic coding c. The prospective payment system d. Increased numbers of catastrophic injuries
C (Feedback: Survival Guide, Chapter 1)
One indicator of quality is: a. Clinical satisfaction b. Coding diagnoses c. Outcomes d. Variance analysis
C (Feedback: Survival Guide, Chapter 14)
The ability of a case manager to demonstrate a skill refers to: a. Knowledge b. Performance c. Implementation d. Competency
D
The basic concept of case management involves a. Denial of services not in a health plan b. Empowerment c. Obtaining certification for therapy d. Timely coordination of quality services
D
The case mangement model which supports and empowers individuals to reach optimum health through the use of community resources is: A) Home health care case management B) Social work case management C) Discharge planning case management D) Community based case management
D
A trend that will impact the delivery of health services is: a. Declining numbers of adults b. Decreases in technology due to budget cuts c. Static numbers of patients with cancer d. An aging nursing workforce
D (Feedback: Leadership and Nursing Care Management, Chapter 14)