CCM Case Manager Practice Questions

1. A financial evaluation is completed for all of the following reasons EXCEPT to:

a. identify available resources for health care and stability
b. determine the client's eligibility for case management services
c. ensure any requisite preapprovals for proposed health care treatments and services.
d. assist a client and family to apply for additional benefits that may be necessary for heath care needs

2. If a necessary medical treatment or service is denied to a patient, a case manager's options include all of the following EXCEPT:

a. misconstruing the client's financial status to meet benefit eligibility
b. requesting a benefit plan exception for circumstances of hardship
c. seeking community resources to provide coverage as needed
d. advocating for a longer stay to meet patient needs, pending the availability of other options

3. Implementation of a plan of care involves all the following EXCEPT:

a. goal setting
b. negotiation
c. contracting
d. delegation

4. The tendency of health care professionals to work in "silos" means:

a. having a multidisciplinary perspective and appreciation
b. referring clients to other providers as needed
c. working independently and without collaboration
d. accepting and receiving consultation as needed

5. Polypharmacy is best defined as:

a. having medications dispensed from more than one pharmaceutical source
b. the pharmaceutical compounding of medicinal blends to provide individually tailored medications and dosages
c. using a team of pharmacists when addressing patient medication issues
d. using multiple medications in a single patient

CCM Case Manager Answers and Explanations

1. B: Determine the client's eligibility for case management services. Clients are referred for case management services based on need, risk, and resource usage, not on their ability to pay for the services. While the extent of services offered may correlate with an ability to pay for those services, financial status is not a prerequisite to case management. A failure to evaluate a client's financial status properly can lead to overlooked resources, services, and even available treatments. Further, failure to complete an evaluation of insurance benefits and coverage may lead to denials of referrals, treatments, and services, and even to costs unnecessarily billed to patients because of a failure to identify, preauthorize, or bill properly for needed treatments and services.

2. A: Misconstruing the client's financial status to meet benefit eligibility. It would be unethical for a case manager to misrepresent (or to coach a client to misrepresent) the client's financial status regardless of cause or need. Such misrepresentation constitutes fraud and can lead to civil and even criminal liability. All other options noted above, however, are within the case manager's purview. Indeed, they are obligations of quality practice and proper client advocacy, as they represent the full development of a patient-centered plan that seeks evidence-based interdisciplinary facilitated outcomes.

3. D: Delegation. A plan that is developed and approved by all involved parties (including the treating physician, the patient and family, and the payer) is not delegated but is implemented by the nurse case manager. While various aspects of treatment and service provision may be delegated to the various disciplines involved, the case manager must not abdicate his or her responsibility to continue the implementation and management of the treatment and service plan. To this end, the case manager uses necessary skills and education in critical thinking, knowledge, evaluation, negotiating, contracting, and decision-making. Goals must be patient-specific and relevant. Negotiation involves building relationships, trust, and flexibility. Contracting is required to engage organizations and vendors to provide the necessary treatments and services.

4. C: Working independently and without collaboration. Professional training has the effect of focusing practitioners primarily on their specialized knowledge base. Thus, there is a natural tendency to practice independently and without collaboration. Consequently, a primary goal of nursing case management is to bring diverse specialties together to address common patient treatment goals and to share unique expertise to meet the identified goals of care. This process of collaboration is primarily carried out by consultation and referral.

5. D: Using multiple medications in a single patient. The situation tends to result from the involvement of multiple physician providers who have little or no interactions with each other and who, thus, prescribe medications without full regard for the other medications the patient is already taking. Polypharmacy situations readily arise in situations of complex chronic conditions and increase the risk of problematic drug interactions, sensitivity, and unanticipated overdose. Issues of unnecessary cost also arise. Competent case managers are uniquely positioned to reduce untoward polypharmacy.