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Flashcards in 60 QUESTION TEST Deck (63):







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1.In which of the following settings should case managers be practicing across "patient transitions of care"?

1.Acute care settings 2.Specialty physician group practices 3.Specialty pharmacies 4.All of the above


2.Predictive modeling allows data to be mined in order to do all of the following EXCEPT:

1.Predict when a patient will develop a disease 2.Examine and recognize patterns 3.Forecast clinical, functional, and financial outcomes 4.Allow patients to be stratified according to risk factors in order to determine the appropriate level of case management/disease management


3.Clinical practice in case management encompasses many roles EXCEPT:

1.Consultant 2.Educator 3.Task manager 4.Resource manager


4.In case management, cost savings are only claimed when:

Claimed savings are less than the cost of case management 2.The case manager is directly responsible for coordinating alternative care 3.Lifetime maximum benefit coverage is exceeded 4.Hard savings can be differentiated from soft savings


5.The federal legislation recognizing health promotion and illness prevention as "a state of complete physical, mental, social well-being; not just the absence of disease or injury" is the:

1.Managed Care Act (MCA) of 1998 2.Partnership for Health Act of 1966 3.Rehabilitation Act of 1973 4.Americans with Disabilities Act (ADA)


6.Evidence-based medicine is defined as:

1.Conscientious use of current best evidence in making decisions about the care of individual patients 2.Use of current best practices in research 3.A systemic approach to the use of research in practice 4.A conscientious use of research-based methodology to deliver care in centers of excellence


7.When preparing to transfer a trauma patient from an acute care facility to a rehabilitation facility, a case manager needs to work closely with the admissions coordinator of the rehab facility to obtain a neuropsychological evaluation. This assessment:

1.Assists in determining out-of-pocket costs for the patient 2.Helps ensure the patient is being transferred to a facility that is closest to where he/she resides 3.Serves as a benchmark for the patient's physical, behavioral, and social improvement during treatment 4.All of the above


8.A letter of medical necessity should include all but which of the following?

1.An introduction of who is requesting the equipment or services 2.A description of why the equipment or services are needed 3.The beneficiary's diagnosis or injury noted as well as the current medical status 4.Identification of legal counsel should the service/product be denied


9.Outcomes Management is:

1.A key component of utilization management 2.A process used by actuarial specialists to differentiate cost-benefit 3.A rationale for further expenditure of dollars in a comprehensive care plan 4.A process of assessing multiple factors including cost, clinical effectiveness, side effects, and patient quality of life


10.A patient may unintentionally engage in polypharmacy when:

1.Seeking competitive drug pricing 2.Purchasing all of his/her medications at the same pharmacy 3.Seeking treatment for addiction to prescription medications 4.All of the above


11.The four elements of negligence include all but which of the following?

1.Duty perceived 2.Duty owed 3.Breach of duty 4.Proximate cause


12.The ethical principle of veracity defines:

1.What is right and fair 2.Refraining from doing harm to others 3.Truth telling 4.Self determination


13.Which of the following is an effective assessment tool for evaluating a patient who is suspected of having substance abuse/addiction problems?

1.The QLQ 2.The GAF scales 3.The BASIS-24 4.The BASIS-32


14.Which of the following is NOT one of the ongoing aspects of case management?

1.Assessment 2.Evaluation 3.Treatment 4.Implementation


16.Which of the following is the first step in the case management process?

Assessment of assigned patients by conducting thorough evaluations of their current status, including medical, financial, psychological, social, and vocational aspects 2.Contacting the assigned patient's primary physician to obtain medical records 3.Screening patients who will be referred to case management services 4.None of the above


17.A case manager is only effective when an appropriate referral has been made, regardless of whether his/her role involves the patient's physical or psychological functioning. Which of the following would be considered an appropriate referral?

1.When it is done in a timely fashion 2.When it is fiscally responsible 3.When it is in the best interests of the patient/family being served 4.All of the above


18.Advance directives are also known as:

1.Living wills 2.Accelerated death benefit 3.The Patient Self-Determination Act 4.The Family Act


19.Software that helps triage patients into case management or even define recommended standards for discharge planning and case management intervention is usually used with:

1.Evaluation management (EM) systems 2.Assessment management (AM) systems 3.Utilization management (UM) systems 4.Case management evaluation (CME) systems


20.A 37-year-old carpenter is unable to return to his previous job and continues to fail in following through with potential job leads provided by his counselor. At this point the case manager would:

1.Refer the client for a vocational evaluation 2.Recommend a transferable skills analysis for the client 3.Assess the client's job readiness 4.Review the labor market trends in the client's immediate area


21.Which of the following is an effective way that case managers can nurture working relationships with the physicians they collaborate with?

1.By assuring physicians that all findings, concerns, and suggestions will be presented for review 2.By providing physicians and their staff with daily reports regarding the case 3.By presenting physicians with a full report at the end of the case 4.All of the above


22.Which of the following is responsible for exercising fiscal responsibility when accepting a referral, receiving a patient into a facility, or arranging a discharge?

1.The attending physician 2.The risk manager 3.The case manager 4.All of the above


23.When an injured employee is receiving workers' compensation benefits, health insurance benefits are:

Primary to workers' compensation benefits 2.Secondary to workers' compensation benefits 3.Converted to COBRA benefits 4.Reduced as a third-party payer


24.Case managers are responsible for referrals that are given or implied. Case managers contact appropriate service providers, in order to determine which of the following

Whether the necessary scope of service can be supplied in a timely, quality-based, and able manner by the provider 2.The cost involved, and if the provider's services and fees are covered by the patient's insurance or other source 3.If the provider has appropriate accreditation, licensure, and levels of staff competency as deemed appropriate by the case manager and/or payer to meet the patient's needs 4.All of the above


25.Subrogation is defined as:

The insurance process by which coordinated payments are made by two or more benefit plans 2.The legal process by which an insurance company seeks from a third party, who has caused a loss, recovery of the amount paid to the policyholder 3.The insurance process by which a healthcare beneficiary can receive out-of-benefit services 4.The legal process by which health plan beneficiaries can recapture out-of-pocket expenses from their primary insurance company


26.The Health Insurance Portability and Accountability Act (HIPAA) provides:

Capability for an employee to move to a new employer health plan without denial or exclusion of benefits if there is no break in group health coverage exceeding 62 days 2.Opportunity for an employee to accept a new job and maintain his/her former group health insurance for 62 days maximum 3.Capability for an employer to exclude a new employee from the group health plan if the employee has a significant medical history 4.Opportunity for an employee to accept a new job and maintain his/her former group health insurance for 18 months


27.The case manager can collaborate with the patient and his/her family to maximize health care outcomes by engaging them in the patient's management plan, which can be effectively accomplished by:

Referring them to other case managers to explain the complex health issues that may be new to them 2.Assessing the family dynamics and its effect on the patient's management plan 3.Assisting in filling out all the appropriate forms to expedite the patient's case through the continuum of care 4.Establishing an individualized approach to the care plan that is suited to their culture, beliefs, and wishes


28.Which of the following is an essential component of the case manager's clinical practice?

1.Specialization in one area of health care 2.Education of the patient and family 3.Assignment of cases in a timely manner 4.Collaboration with third-party payers


29.Prior to performing an assessment of the patient, the case manager must obtain authorization from:

The patient 2.The payer 3.The attending physician 4.The healthcare team leader


30.Which of the following is said to be the glue that binds all of the processes of case management?

Assessment 2.Coordination 3.Collaboration 4.Evaluation


31.An important component of the care plan for an AIDS patient returning to work is:

Arranging for special benefits for the employee from the employer under the Right to Work with AIDS Act 2.Educating coworkers about HIV prevention 3.Recognizing the employee's right to confidentiality 4.Informing the employee's human resource department of the employee's right to receive AIDS assistance


32.If case management intervention is not in the best interest of the patient, the independent case manager receiving a patient referral from a payer should:

Refuse the case, even if the payer source pre-approves payment for case management services 2.Contact the patient to explain why case management interventions can improve his/her outcomes 3.Contact the payer to discuss a method to educate the patient about case management services 4.Contact the payer to ensure the patient is not subsequently billed for the approved case management services


33.A traumatic brain injury patient is referred to an independent case manager by his guardian, who guarantees payment of services. As the case manager gathers facts, she learns the patient has group health insurance coverage. Which action is most ethical?

Contact the patient's group health insurance plan and notify them that she is the newly appointed case manager for the patient 2.Contact the patient's group health insurance plan to verify if it provides for catastrophic case management services 3.Advocate for the patient and his family as the patient transitions through different care settings 4.Coordinate with the rest of the patient's care team to ensure optimal healthcare services are provided


34.For a brain injury patient initially treated in the acute care setting, a common measuring tool used to determine cognitive response is the:

Ranchos los Amigos Cognitive Scale 2.Villa del Luego Scale 3.Glasgow Coma Scale 4.Both 1 and 3


35.Care plan goals for the oncology patient may include all but which of the following?

Limiting discussion about end-of-life issues 2.Recognition and ongoing management of common conditions of chemotherapy 3.Recognition and ongoing management of pain 4.Psychosocial and economic support for the patient and family/caregiver


36.The ethical principle of autonomy states that the case manager should:

Do good and prevent harm 2.Make decisions regarding advance directives 3.Promote paternalism 4.Respect the wishes of the patient


37.CQI is a:

Healthcare delivery model 2.Voluntary mechanism to control costs in managed care 3.Cyclical process to assess, measure, change a process, remeasure, and reassess for ongoing incremental improvements 4.Required component of the HIPAA law


38.Measuring traditional case management outcomes can include all but which of the following?

Patient satisfaction 2.Quality of life 3.Cost benefits of physician selection 4.Clinical effectiveness


39.Outcomes in case management reporting are used to:

Measure patient satisfaction, quality of care, and cost savings 2.Measure the turnaround time in the patient's recovery 3.Assist in determining the patient's present and future medical needs 4.Assist in determining appropriate reimbursement to the provider


40.The case management activity which could most likely result in liability for the case manager is:

Documenting a patient's noncompliance with the recommended treatment plan 2.Checking insurance benefits to determine limitations of the case manager's plan 3.Determining the level of appropriate medical care 4.Determining options to the benefit plan


41.The role of resource management includes:

Screening for benefits eligibility 2.Screening for diagnostic procedures 3.Triaging patients into case management 4.Assumption of risk


42.A client usually reaches MMI when:

The claims adjuster determines maximum medical improvement 2.All of the healing benefits possible from medical treatment have been achieved 3.2 years maximum post-injury have occurred 4.The client elects to obtain an attorney and seek legal action


43.Overutilization is defined as:

A pattern of excessive billing practiced by providers 2.A pattern or practice of overusing or overprescribing medical services 3.The subject of DRG dispute resolution 4.Excessive use of case management by a patient


44.Clinical pathways based on case management plans were developed to:

Improve communication between the patient and physician 2.Show specific interventions that should occur in a stated time frame 3.Promote early discharge of the patient from the acute care facility 4.Improve adherence to InterQual criteria


45.One way to optimize outcomes in disease management is to:

Focus expenditures on the sickest, most costly enrollees in the plan 2.Target high-cost, high-risk individuals at the earliest stage possible to minimize treatment costs and maximize quality 3.Focus efforts on increasing drug usage 4.Target low-cost, low-risk individuals to maximize member profiles


46.This modality is useful in utilization management for helping reduce the underuse, overuse, and misuse of medical resources:

Critical pathways 2.InterQual 3.LOS 4.Milliman Care Guidelines


47.Which of the following nursing methods of assessing technologies involve securing and reinforcing the person's physical, psychological, and social ability to function and to cope with daily activities, enhancing his/her sense of wellbeing?

Therapeutic methods 2.Methods of promotion and maintenance 3.Preventive methods 4.Rehabilitative methods


48.Under the Americans with Disabilities Act, the individual responsible to identify essential job functions is the:

Employee 2.Case manager 3.Employer 4.Claims adjuster


49.A well-written cost-benefit analysis by the case manager will show:

How the case manager plans to petition the medical director for out-of-benefit services 2.Cost effectiveness of the equipment or services to the plan of care 3.How funds spent in the long-term will maximize saving in the short-term 4.The expected cost of caring for the individual for his/her expected life span


50.SSDI payments are meant to:

Provide accelerated disability payments as governed by each state 2.Replace part of earnings lost because of an impairment that prevents an individual from working 3.Bring a disabled individual to a level of economic self-sufficiency 4.Provide social security income for all persons over the age of 65


51.Risk management focuses on:

Loss prevention of adverse patient outcomes 2.Increased probability of quality patient outcomes 3.Adherence to professional standards 4.Continuous quality improvement


52.A document that provides a fundamental and meaningful way to explore how the process of case management is engaged by the care coordination team is the:

The Joint Commission Standards 2.Case Management Society of America Standards of Practice (CMSA) 3.URAC Guidelines 4.NCQA HEDIS Standards


53.Performance indicators indicated in the CMSA Standards of Practice consist of all the following EXCEPT:

Confidentiality 2.Resource Management 3.Engaging Outcomes Collection and Reporting 4.Cultural Competence


54.In the initial contact phase, a disability management case manager will make contact with:

The client, plaintiff attorney, and claims adjuster


55.Case closure for a patient with a workers' compensation injury is determined when:

Funds are exhausted 2.The healthcare team has met its goals 3.The client has reached maximum medical improvement 4.The adjuster withdraws medical treatment benefits


56.The correct relationship between breakthrough pain (BTP) and acute pain is:

Acute pain is shorter in duration than BTP 2.BTP incites the onset of acute pain 3.Unlike acute pain, BTP has no underlying cause 4.There is no relationship, as BTP affects patients with chronic pain


57.Which of the following is a correct statement regarding Health Insurance Exchanges?

They offer health plans that can be purchased by visiting a local marketplace 2.They are state-run virtual marketplaces where health plans can be compared 3.They provide a means of exchanging benefits with persons on other health plans 4.They are federally mandated requirements for non-private health plans


58.Care Coordination is a concept initiated under the Affordable Care Act to achieve:

Controlled costs and reduced medical/medication errors and hospital readmissions for patients with chronic diseases 2.Coordination of all inpatient and outpatient services into a single site, called the Patient-Centered Medical Home (PCMH), in order to minimize transitions of care 3.Increased accountability in health information exchange via creation of Accountable Care Organizations (ACOs) 4.Increased involvement of case managers to educate colleagues about resource management


59.What is the difference between an electronic medical record (EMR) and an electronic health record (EHR)?

EMRs construct a comprehensive patient history from information entered by multiple providers and organizations 2.EMRs aggregate health information from a patient population to provide measurable data 3.There is no difference, as "EMR" and "EHR" are interchangeable names for the same form of health information technology 4.EHRs are designed for digital transfer of patient health information between providers and organizations


60.In order to become certified as a nurse case manager by the ANCC, a professional nurse must first be able to demonstrate competency in each of the following Domains of Practice, EXCEPT:

Resource Management 2.Cost Management 3.Quality Management 4.Education


15.Which component(s) of healthcare management help(s) a case manager determine a patient's physical and psychological functioning?

Assessment tools 2.Diagnostic tests 3.Physician and mental health expert diagnosis 4.Both 1 and 2