1000 Word Essay

TCM 56 May/June 2003

ase managers in managed care organizations (MCOs) face emerging legal and ethical challenges. Factors such as increasing pressures to control costs, inadequate training and preparation, lack of evidenced-based guidelines, unclear or unrealistic role expectations, changing legislation, and insufficient medical or administrative support can increase the risk for negligent referrals and bad-faith denial of care and the stress of ethical dilem- mas. This article proposes strategies to deal with and prevent potential dilemmas.C

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by Alison G. Hendricks, RN, MN, MBA, CCM, and W. Jennifer Cesar, RN, JD

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Defining Terms The Case Management Society of Amer- ica1 (CMSA) defines case management (CM) as a collaborative process of assess- ment, planning, facilitation, and advoca- cy for options and services to meet an individual’s health needs through com- munication and available resources to

promote quality, cost-effective out- comes. Mullahy2 defined managed care as a system that provides the general- ized structure and focus when manag- ing the use, cost, quality, and effective- ness of health care services. It is the umbrella for several cost-containment initiatives. Examples of managed care

structures include health maintenance organizations (HMOs), preferred provider organizations, independent practice associations, primary care net- works, exclusive provider organizations, and point of service networks. Generi- cally, these entities are referred to as MCOs.

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Case Manager Credibility The CMSA1 National Standards of Prac- tice, first published in 1995, help define the case manager ’s duty to patients. However, to represent one’s self as a specialist is to be expected to provide special expertise. Therefore, the case manager will be held to a different legal standard than that of the basic regis- tered nurse. Provision of substandard services (care) to a patient may result in charges of negligence or professional malpractice.3

A controversy exists as to whether stan- dards and guidelines are used more often to impose liability (inculpatory) or clear practitioners exposed to liability (exculpatory) when applied in case law.4

The evidence to date demonstrates that standards and guidelines are used most often in court cases to prove liability.4

Although this inculpatory effect alarms some practitioners, plaintiff attorneys are less likely to pursue cases when neg- ligence can be disproved by document- ed adherence to guidelines.4

HMOs The HMO Act of 1973 was implemented in 1978 to permit prepaid medical plans to function as an alternative to private health insurance.5 The Centers for Medicare and Medicaid Services (CMS), previously the Health Care Financing Administration, regulates HMOs. HMOs generally provide a specified scope of benefits in return for a fixed monthly premium known as a capitation pay- ment. If the HMO provides services for less than the capitation fee, it keeps the residual as profits. This structure pre- sents an inherent incentive to limit costs related to patient care in order to maxi- mize profits.

However, each HMO must provide the same minimum benefits for elder and disabled people that otherwise are avail- able under Medicare.5 These plans may, subject to certain limits, charge enrollees (members) additional premiums, coin- surance, or copayment amounts. Enrollees agree to receive all covered benefits through the plans. HMOs may provide additional benefit coverage, depending on negotiated contracts with individual employer groups. In Califor- nia, HMOs are required to have a Knox- Keane license to market and contract services with employer groups.5

The HMO often subcontracts with a physician provider group (MCO model), which in turn provides the care. The HMO retains a certain amount of the Medicare capitation dollar for adminis- trative services, such as marketing and regulatory compliance costs. In return, the physician provider groups contract with all necessary suppliers and vendors to provide a comprehensive network of services for members. The financial risk of each entity varies according to the nature of the contracts, but the concept of minimizing cost to optimize profits remains the same.

Although case managers cannot be expected to know every detail of each managed care contract that affects their patients, without a basic understanding they may be placed in a position of mov- ing from patient advocate to adversary.6

Not only do managed care contracts determine what benefits the patient receives, but they often direct the care the physicians provide. Physicians often rely on case managers to communicate the patient’s benefit coverage and direct the care to contracted providers. Services that are not covered under the patient’s benefit plan or by contracted providers may be denied for coverage. In addition, if a patient has more than one type of insurance (eg, Medicare and HMO), the case manager must determine which insurance coverage applies.

Case Manager’s Role in the Denial of Service Case managers perform an important role in the denial of service process. Although under their scope of practice case managers cannot determine whether a service is medically appropri- ate (determined only by a physician), she can recommend approval or denial of payment based on several other factors. First, the case manager determines whether the requested service is a cov- ered benefit under the patient’s health plan. If it is not, this is communicated to the patient and physician as a denial because of lack of financial coverage. The patient, however, may opt to pay for the service out-of-pocket if he chooses. The case manager also can help the patient find alternative sources of funding.

Second, the case manager can deter- mine if the requested service falls with- in the contracted provider network. If

not, the service may be denied based on recommendations to redirect the service to a contracted provider. Again, the patient may choose to pay for the noncontracted provider out of pocket if he chooses.

If the requested service is denied based on either of these scenarios, the patient has a legal right to appeal the decision. Federal and state regulations require MCOs to establish a process for physi- cians and members to appeal benefit coverage and medical management decisions.7 An appeal based on clearly defined benefit coverage rarely is over- turned. However, determinations based on medical necessity often are based on medical opinions, and the health plan may overturn the provider network’s decision if they determine it is in the best interest of the patient.

Laws Related to Denial of Service Several laws determine liability and duty related to denial of services in MCOs. Case managers need to be knowledgeable of these laws to make certain their practice conforms to them. The following paragraphs briefly outline a few of these major regulations.

The Employee Retirement Income Security Act (ERISA) of 1974 was designed to ensure that employee wel- fare benefit plans conform to a uniform body of law.8 The law, however, does not regulate the contents of the benefit plans themselves.8 Rather, it governs most nongovernmental employee bene- fit plans and exempts companies that self-insure from meeting the same mini- mum benefit regulations that govern insurance companies.2

ERISA pre-empts state law causes of action, whereby state laws that relate to employee benefit plans are superseded by ERISA.8 When the ERISA pre-emp- tion applies, claimants must sue under the federal law and are limited to the damages permitted under ERISA rather than the more liberal damages available under state law.7 However, this limita- tion on damages was curtailed in 1997, when California Congressmen Pete Stark (D-Hayward) and George Miller (D-Martinez) 2introduced the Managed Care Plan Accountability Act (HR 1749). HR 1749 would eliminate the ERISA law that would have blocked any punitive

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damages, therefore allowing more suits against managed care companies for punitive damages.9

When a case involves state laws (related to employee benefit plans), exclusions to ERISA occur only if the corporate/ administrative aspects of the managed care plan, not the medical malpractice, are seen as relating to the employee benefit plan.8 In this scenario, the medi- cal malpractice action falls outside the ERISA pre-emption and could be pur- sued under state law.8 In other words, the judicial perspective is to handle any case involving medical determinations (medical necessity) as raising quality of care issues, not denial of benefits, there- fore allowing the survival of an action that might have been dismissed under ERISA pre-emption of state malpractice and or other state laws.10

The Tax Equity and Fiscal Responsibili- ty Act of 1982 made Medicare secondary to employer group health plans for active employees 65 to 69 years old.2 It also revised the Age Discrimination in Employment Act of 1967 by requiring employers to offer active employees age 65 to 69 and their spouses the same health benefits as those available to younger employees.2

The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 eliminated the age cap of 70 and made the employer ’s plan the primary payor for all active Medicare-eligible employ- ees and their spouses, regardless of age.2

In addition, the Omnibus Budget Rec- onciliation Act (OBRA) of 1986 made private employer health plans primary and Medicare secondary for claimants who were permanently disabled and were covered dependents under a working spouse’s health plan or for claimants who returned to active employment.2

The Civilian Health and Medical Pro- gram of the Uniformed Services (CHAMPUS) allows retired and active military personnel and their dependents access to treatment at any Department of Defense medical facility. Retired per- sonnel are eligible under CHAMPUS if they are not eligible for Medicare.2

The Family and Medical Leave Act (FMLA) of 1993 ensures that employees

who take a leave of absence of up to 12 weeks are eligible to maintain health benefits.2 According to government rules, worker ’s compensation leave can count against the 12-week FMLA leave.2

In this case, the employer is not required to pay health benefits beyond 12 weeks if the worker cannot return to his or her job, in which case COBRA benefits should be assigned.2

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 curbs employers’ ability to deny health benefit coverage to employees with pre- existing medical conditions and allows medical savings accounts on a trial basis for employers with fewer than 50 employees.2 It also includes amend- ments that set a timetable for putting in place privacy regulations and electronic standards for medical recordkeeping and penalties for breaking them.2

The Health Centers Consolidation Act of 1996 includes a definition of “required primary health services,” incorporating the right for patient case management services.2

Other legislation in the making includes the Comprehensive Long Term Care Act of 1997,2 which would require case man- agement plans and permit a Medicare beneficiary to request CM assessment regarding one’s status as a “dependent individual.”2 In addition, the Medicare Patient Choice and Access Act of 1997 allows direct access to a specialist, with- out authorization, as determined by the case manager and provider.

Case Management Liability Related to Denial of Service The allocation of legal risk to providers historically has been based in large part on their authority to make decisions regarding patient care.11 As case man- agers for payors appropriately become more aggressive in influencing patients’ care plans, many providers have begun to question the fairness of being assigned all risk of legal liability. Indeed, patient attor- neys are focusing attention on case man- agers as defendants in lawsuits involving negligent premature hospital discharge of patients or negligent denial of payment of services.11 The case manager must have a greater breadth of general knowledge and a greater depth of understanding of legal principles and law.11

To hold case managers liable for negli- gent denial of payment for services, the patient must prove the following:3

• The case manager had a duty to make a reasonable payment decision.

• The case manager breached her duty by making an inappropriate payment decision.

• The breach of duty resulted in injury or damage.

• The withholding of payment was unreasonable in view of applicable standards of care.

• The breach of such duty was the actu- al and legal cause of the resulting injury or damage.

In the 1990 case Wilson v. Blue Cross of Southern California, the court ruled that payment decision-makers are liable for injuries to patients whether or not the providers protest.3 However, in a subse- quent 1990 case, Varol v. Blue Cross of Michigan, the court ruled in favor of Blue Cross, concluding that the providers had a legal and ethical obliga- tion to render care whether or not they were paid for it.11 Although no case manager has been held personally liable for denial of care decisions thus far, the trend toward liability is increasing.

Service providers have taken action to protect themselves against liability for delayed payments of claims. In Rogers v. Cigna HealthCare (2001), Texas physicians filed a class-action lawsuit against Cigna alleging that the company avoided pay- ment of medical services rendered.12 In addition, the Maryland Insurance Com- missioner issued disciplinary orders, including $1.4 million in administrative penalties, against 5 health plans in 2001 for allegedly failing to pay claims within the required 30-day time frame and failing to comply with other state insurance laws. The penalty against each health plan ranged from $25,000 to $600,000.12 In view of these trends, case managers are under- standably seeking ways to avoid liability.11

An allegation of bad-faith denial of an insurance claim can be based in either contract or tort law.8 The difference involves the damages available and the applicable statute of limitations for

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bringing the action. Both types of actions are based on the allegation that an MCO breached its duty based on bad faith when it denied benefits or autho- rization to provide covered services. The elements of bad faith denial generally are defined as the absence of a reason- able basis for denying benefits and the insurer ’s knowledge or reckless disre- gard of the lack of a reasonable basis for denying payment.8

Insurers have been found liable for fail- ing to contact the member ’s attending physician to discuss the patient’s condi- tion before denying coverage, failing to obtain the patient’s progress notes and follow procedures for claims review before determining that services were not medically necessary, and failing to inform a member of the right to appeal an adverse decision and settle disputes through arbitration.8 As a result, most states have adopted variations of the National Association of Insurance Com- missioners’ (NAIC) Unfair Claims Settle- ment Practices Model Regulation, which specifies how insurers should process claims and notify beneficiaries of claims determination.8 State laws based on the NAIC model require fair and timely claims evaluation and written notice of claims denial that indicate the basis of denial.8 Case managers involved in denial of payment and claims adjudica- tion should be familiar with these laws.

In addition, emerging legislature is aimed toward giving patients a wide range of new rights, including the right to sue health insurance plans that cause injury by denying care or by providing substandard treatment.13 House mea- sures include some provisions that are similar to those approved by the Califor- nia Legislature and signed into law by Governor Davis.13

Case Law Related to Denial of Service Although hundreds of cases have affect- ed managed care, two in particular stand out in regard to denial of services. The first case involving liability for a uti- lization review decision was the 1986 Wickline v. State of California.8 In this case, the court said, “Third-party payers of health care services can be held legally accountable when medically inappropri- ate decisions result from defects in the design or implementation of cost-con-

tainment mechanisms.”14 This landmark case has elements pertinent to both CM and discharge planning practices and is possibly the most well-known case nationally that deals with these issues.15

As such, it often is referred to by attor- neys and other experts who speak on malpractice at CM meetings.15

The specifics of this case involved a Medicaid patient who was medically eli- gible for continued hospitalization. However, the patient was discharged prematurely when the attending physi- cian failed to seek an additional exten- sion because he believed the Medi-Cal (Medicaid) consultant put the state’s interest above the patient’s welfare.15

The court ultimately found Medi-Cal not liable based on the fact that the final decision for discharge rests with the attending physician.15

The second landmark case demonstrates bad faith on the part of the insurer.5 In the 1996 California case of Fox v. Health- net, the courts awarded the estate of Nelene Fox $89.3 million based on the insurer ’s refusal to pay for a bone mar- row transplant. Though Fox had met all benefit provisions for treatment of her metastatic breast cancer, Healthnet refused to pay.5 The Healthnet man- agers even went so far as to persuade her treating physician to reverse his rec- ommendation for the procedure.5 Fox was able to raise money herself and received a transplant after a delay of 2 months, but she died 8 months later.

Exacerbating the situation was the fact that Healthnet paid the utilization exec- utives bonuses based on the total dollars in medical care denied during the year.5

The court found that Healthnet evi- denced bad faith because it placed earn- ings before the interests of its sub- scribers and actively conspired to deny appropriate medical care.5

Another similar case is a 1999 suit involving Humana. The core allegation was that Humana falsely represented to its enrollees that all coverage and treat- ment decisions would be made on the basis of medical necessity when, accord- ing to the plaintiff, Humana:10

• Based its coverage and review deci- sions “on a variety of concealed cost- based criteria that were unconcerned

with, and sometimes inimical to, the medical needs” of enrollees

• “Concealed” from enrollees “that it has established a set of financial incentives for claims reviewers— including direct cash bonus pay- ments—designed to encourage denial of claims without regard to [the] med- ical needs” of enrollees

• “Concealed” from enrollees that it “subcontracts the claims review pro- cess and with it the authority to decide the scope of [enrollees’] medi- cal coverage to third parties” who hired “persons without appropriate medical training and specialization to make claims review determinations” and use “criteria different from and more restrictive than” Humana’s medical necessity criteria

• “Concealed” from enrollees that it “provides direct financial incentives to treating physicians and other health care professionals to deny coverage” to enrollees “even where the pro- posed treatment satisfies medical necessity definition.”

Furthermore, the prosecution claimed, “By means of this wrongful conduct,” Humana provided enrollees with “bene- fits of lesser value than the benefits” that the company indicated enrollees would receive. As such, the suit alleges, enrollees were harmed and Humana was “unjustly enriched” in an amount “equal to the difference in value between the coverage described in” the Humana health plans “and the coverage actually provided” to enrollees.10

The implication of these landmark cases for case managers is evident. Because of the current emphasis on cost contain- ment and because case managers can be held liable for the patient’s care and ulti- mate welfare, case managers should not comply with any unreasonable demands by MCOs or payors without formally protesting or stating their positions in writing.15 The medical director and case manager should extensively document denials and their rationale. As previously mentioned, other cases have held that liability may exist whether or not protest occurs. However, clear documentation can help demonstrate whether the case manager acted in good faith.

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Ethical Considerations Related to Denial of Service Closely connected with questions of legality are questions of ethics and morality.2 In any health care delivery sys- tem, the primary motivation should be the health, welfare, respect, and dignity of the individual treated.2 The underly- ing moral and ethical principles and val- ues attached to these motivations include autonomy, beneficence, fidelity, justice, nonmalfeasance, and veracity.2 These principles are at the core of patients’ rights and CM responsibility.2 Case man- agers more often than not are in a fidu- ciary relationship with the client that implies one party ’s inferiority of knowl- edge and dependence on fair treatment by the other party. In other words, the case manager is in a position of trust and confidence, and the client depends on her to take due care and act in good faith. Provision of substandard services (care) to the patient may result in charges of breach of fiduciary duty.3

Many of the ethical choices that case managers face are money driven.2 As the pressures to contain costs mount, case managers increasingly are finding them- selves in more ethical dilemmas.2 For example, questions such as whether or not a patient was well enough to be dis- charged from a hospital or receive a cost- ly high technology procedure were rarely issues in the past. Today, they are com- mon occurrences. In fact, the discipline of CM occurred as a direct response to both technologic advances and the monetary constraints and issues that have resulted from managed care.2 In addition, because health care is now managed like a busi- ness, health care professionals often find themselves reporting to business man- agers who might not understand or be sympathetic to their ethical dilemmas.2

The Dilemma Triad Three of the most common dilemmas encountered in CM are focus of advoca- cy, supremacy of values, and conflict of duties.5 Focus of advocacy concerns whom the case manager is a supporter for: the patient, family, insurer, employ- er, and society at large.5 The answer should be “to all the above,” but the best interests of each of these parties are not always harmonious and may be in con- flict. For example, the insurance compa- ny wants to limit its medical expendi- tures, the patient may need more

benefits than he or she is entitled to, the family may be impoverished by funding care, and unrestricted medical spending raises the cost of medical care beyond the reach of some members of society.5

In terms of supremacy of values, a case manager naturally tends to make deci- sions that are harmonious with his or her values.5 However, some decisions made by the case manager in the best interest of the organization require him or her to violate the patient’s or her own values. The questions of whose values should have supremacy in any given sit- uation may present an ethical dilemma.

Relating to conflict of duties, a case manager has a responsibility to put the best interests of the client first; however, such decisions may have an adverse effect on another party ’s.5 Some com- mon examples of this dilemma involve confidentiality. For example, should the case manager inform the insurer if she becomes aware that the medical condi- tion currently being paid for pre-existed and may not be eligible for coverage under the policy? These questions are not easily answered.

To assist case managers in their day-to- day practice, the industry has respond- ed with standards of practice and codes of conduct.2 In February 1996, CMSA issued the Statement Regarding Ethical Case Management Practice to “provide guidance to the individual case manager in the development and maintenance of an environment in which practice is conducted ethically.”2 The Commission for Case Manager Certification adopted its Code of Professional Conduct for Case Managers with Disciplinary Rules, Procedures, and Penalties in November 1996, incorporating three kinds of stan- dards, along with guidelines and proce- dures for processing complaints and possible sanctions.2 The code was designed to ensure that certified case managers accept responsibility that their actions or inactions can aid or hinder clients in achieving their objectives and that they provide services in a manner consistent with certain standards.2

Limiting Liability in Denial of Service In light of the nursing shortage, many organizations are hiring temporary CM staff to fill vacant positions. Temporary

case managers are representatives of the temporary staffing agency.16 The written contractual arrangements between the MCO and the agency should clearly state which entity will bear responsibility, both financially and for service performance, in the event problems occur. This arrange- ment does not negate the agency’s ongo- ing duty to supervise and assess the per- formance of all services rendered.16

In addition, the temporary agency should carefully screen and review the MCO’s credentials before assigning a qualified case manager to the job. For example, establishing policies that the agency will contract only with accredited and licensed facilities may minimize risk to both the case manager and the agency. As part of the contract, the agency may specify that the MCO provide support- ing documentation of quality assurance mechanisms, and vice versa.16 One example includes ensuring the MCO has appropriate CM structures and process- es, such as access to knowledgeable supervisors and medical directors for administrative and clinical decisions, in addition to well-defined procedures and protocols for denial issues.

Assessing the MCO’s relationships with contracted vendors and service providers is also critical.16 Each ensuing contract requires the case manager to determine what conditions and restrictions apply before making approval or denial deci- sions.16 The payor contract, for example, may state that home care and medical supplies cannot be obtained from out-of- network vendors, even though the quali- ty of care may be superior; such restric- tions may reflect on the quality of CM services and may place the case manager at risk.16 Careful assessment and evalua- tion of these issues on the part of the case manager can go a long way in limit- ing risk and liability.

Maintaining Standards of Practice Careful screening of licensure, certifica- tion status, and competency is impera- tive to minimize hiring risks. Although CM certification is not required by law to work as a case manager, the MCO may limit liability by hiring only indi- viduals who either have or are pursuing certification. In addition, the MCO should perform ongoing skills/compe- tency validation checks to ensure quali- ty of performance and ethical training.16

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Specific guidelines outlining this process should be developed and clearly com- municated, in contractual language, to the case manager as a condition of ongoing employment.16 Also, mecha- nisms should be implemented to obtain ongoing feedback from MCOs related to ethical staff performance.

Furthermore, MCOs should monitor com- pliance with standards of practice and ethical code of conduct guidelines. They should work collaboratively to ensure that practice guidelines are systematically developed to assist the case manager in making appropriate care decisions. An example is to develop a policy and proce- dure addressing level of medical review for decision-making in regard to approval or denial of care. Denials based on medi- cal necessity should be made only by the organization’s medical director. Also, to further minimize liability, the case manag- er should document close coordination with treating physicians and document all treatment recommendations, decisions, and rationale.16 CM decisions should be based on supporting guidelines whenever possible.16

Clear documentation of interventions, collaboration, and protocol compliance is important in limiting liability.16 In addi- tion, an evaluation of each patient’s ben- efits should be clearly documented in the medical record before service denials or approvals are made because benefit cov- erage may change frequently.16 It is also important that case managers clearly communicate and document their role and credentials to avoid the appearance of making medical decisions,16 as well as include out-of-pocket options so that any denial of payment does not become syn- onymous with denial of care.16

Outcome Monitoring MCOs should be required to monitor quality outcomes related to CM. Examples of outcome indicators include evidence of and compliance with written policies and procedures, evidence of staff education and qualifications, staff and patient satis- faction, patient and staff grievances and complaints, overturned denials, compli- ance with professional standards, compli- ance with documentation standards, and accreditation and regulatory compliance.

Examples of CM guideline compliance include performing comprehensive nurs-

ing assessments of patients, developing a written plan of care, knowing and com- municating benefits, maintaining appro- priate and accurate documentation of recommendations and alternative treat- ment options, collaborating with all members of the health care team, and ensuring timely and appropriate deci- sions based on established processes for the provision of adequate care.

Conclusion CM is an effective strategy to providing collaborative, coordinated, and cost-effi- cient delivery of health care services to managed care members. However, the case manager must be cognizant of the responsibility and liability that accom- panies the role of being at the center of the delivery of care to patients. It is imperative that case managers take steps to prevent risks that would expose them to liability and to limit liability by mitigating culpability as evidenced in adequate documentation. The reward for the case manager who recognizes and understands the standards of care and practices at or above them is decreased liability exposure. The greater reward, however, is the professional stature and prestige as autonomous, well-educated leaders and innovators who are willing to accept responsibility for clinically and legally appropriate decision-making.3 ❑

References 1. Case Management Society of Amer-

ica. Standards of practice for case management. Little Rock (AR): The Society; 2002.

2. Mullahy C. The case manager ’s handbook. Gaithersburg: Aspen Publishers; 1998.

3. Ely-Pierce K. Legal issues for case managers: what you don’t know can hurt you. Family and Commu- nity Health 1999 Oct. Available at: www.findarticles.com/cf_0/m0FSP/3_22 /56908981/p1/article.jhtml?term=legal +issues+for+case+manager.

4. Gosfield A. Guidelines in case man- agement. Case Manager 1997;8:103-8.

5. Howe R. Medical case manage- ment: forms, checklists and guide- lines. Gaithersburg: Aspen Publish- ers; 1999.

6. Hiepler M. A delicate balance: case managers walk a fine line between patients and payors. Case Manage- ment Advisor 1998;113-4.

7. Knight W. Managed care: what it is and how it works. Gaithersburg: Aspen Publishers; 1998.

8. Conner C, Cartwright K, Kole S, Forsyth G, Mohre E. Managed care law. Gaithersburg: Aspen Publish- ers; 1999.

9. Federal bill would ax ERISA barrier to lawsuits, legal challenges to man- aged care, ERISA and lawsuits against managed care companies. Best of CCEMHC News 1997 Sum- mer. Available at: www.ccemhc.org/ 12berisa.html.

10. Shaw PP. Managed care challenged in class action lawsuit (the Humana lawsuit). Government Regulation/ Health Law 1999 Oct. Available at: library.lp.findlaw.com/library/firms/sp/ pdf/sp000009.pdf.

11. Hogue E. Are case managers liable? J Care Management 1995;1:35-9.

12. Managed care briefs. Managed Care Week 2001;11:5.

13. Pear R. House OKs rights bill for patients. Press Enterprise Section A, page 4, 1999 Oct 8.

14. California Law. 239 Cal. Rptr. 810 (Ct. App. 1986), review dismissed, remanded, 1987. 741 P.2d 613.

15. Rossi P. Case management in health care. Philadelphia: WB Saunders; 1999. p. 5.

16. Muller L. Provider contracts: what case managers need to know. J Care Management 1998;4:60-5.

Alison G. Hendricks, RN, MN, MBA, CCM, is the cofounder of a California-based independent care management organization. W. Jennifer Cesar, RN, JD, practices in Orange County, Calif., specializing in health care quality and risk management.

Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. YMCM 46 doi:10.1067/mcm.2003.46

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CEU APPLICATION

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This article has been approved for 1 hour of CCM, CRC, and CDMS education credit by The Foundation for Rehabilitation Education and Research.

To obtain your education credit, please do the following: 1. Read the “How Prepared Are You? Ethical and Legal Challenges Facing Case Managers Today ” article. 2. Make copies of this page for each person applying for credit. 3. Answer the following questions by selecting one statement. Four questions must be answered correctly to receive the

educational credit. 4. Mail this completed form with a check for $10 to:

Foundation for Rehabilitation Education and Research 1835 Rohlwing Rd., Ste. E, Rolling Meadows, IL 60008

Questions: For which educational credit (1 hour) are you applying?

CCM ID#___________ CRC ID#___________ CDMS ID#__________

1. The following statements are true for HMOs EXCEPT: _____A. HMOs must provide the same minimum benefits for elderly and disabled members that otherwise are

available under Medicare. _____B. Services that are not covered under the patient’s benefit plan or by contracted providers may be denied

for coverage. _____C. Case managers have the authority to deny coverage based on whether or not a service is medically

appropriate. _____D. Case managers determine whether a requested service is covered under the patient’s health plan.

2. The following statements regarding ERISA are true EXCEPT: _____A. ERISA pre-empts state law causes of action whereby state laws that relate to employee benefit plans are

superceded by ERISA. _____B. Exclusions to ERISA can occur if medical malpractice is seen as related to the employee benefit plan. _____C. When the ERISA pre-emption applies, claimants must sue under federal law and are limited to the

damages permitted under ERISA rather than the more liberal damages available under state law. _____D. ERISA law does not regulate the contents of benefit plans.

3. To hold case managers liable for negligent denial of payment for services, which of the following must be proved? _____A. The case manager had a duty to make a reasonable payment decision. _____B. The case manager breached a duty, resulting in injury or damage. _____C. The withholding of payment was unreasonable in view of applicable standards of care. _____D. All of the above

4. Underlying moral and ethical principles that are at the core of patient rights include all of the following EXCEPT: _____A. Autonomy _____B. Forgiveness _____C. Nonmalfeasance _____D. Justice

5. Strategies to limit liability related to denied services include which of the following? _____A. Case manager decisions are based on supporting guidelines. _____B. Case managers provide clear documentation of interventions, collaboration, and protocol compliance. _____C. Managed care organizations monitor compliance with standards of practice and ethical code of conduct

guidelines. _____D. All of the above

Name ______________________________________________________________________________________________________

Address ____________________________________________________________________________________________________

City ___________________________________________________ State __________________ ZIP ________________________

Signature ___________________________________________________________________________________________________

An individual application and $10 payment must accompany each request. Applicants who do not score 80% or higher may reapply with another application and additional $10 payment. No refunds will be issued for the $10 processing fee, regardless of the certification an applicant holds. Docu- mentation of credit and an approval number will be mailed from the foundation in 3 to 4 weeks. Credit available from May 1 to July 31, 2003.