CCM - Certified Case Manager Reimbursement and Utilization Management Questions and Answers 2 — Questions and Answers
Question 1: What is the primary difference between Medicare Part A and Part B?
- Part A for younger, Part B for older
- Part A covers inpatient/institutional services; Part B covers outpatient/professional/preventive/DME services (Correct answer)
- Part A is free, Part B has a premium
- Part A covers prescriptions, Part B covers hospitalizations
Correct answer: Part A covers inpatient/institutional services; Part B covers outpatient/professional/preventive/DME services
Part A covers inpatient and institutional services; Part B covers outpatient, professional, and preventive services.
Part A covers inpatient hospital, SNF, hospice, and some home health. Part B covers physician services, outpatient care, preventive services, DME, lab tests, and ambulance services.
Question 2: What is prior authorization and the case manager's role?
- Authorization before entering a hospital building
- Insurance approval before certain services, with the case manager facilitating clinical documentation (Correct answer)
- Legal authorization from patient to doctor
- Authorization before case management begins
Correct answer: Insurance approval before certain services, with the case manager facilitating clinical documentation
Prior authorization requires insurance approval before certain services, with case managers providing clinical justification.
The case manager identifies services requiring authorization, gathers clinical documentation, communicates with providers and insurers, tracks status, facilitates peer-to-peer reviews, and initiates appeals when needed.
Question 3: What is a Diagnosis-Related Group (DRG)?
- A group of physicians sharing a specialty
- A patient classification determining fixed reimbursement based on diagnosis, procedures, age, and complications (Correct answer)
- A diagnostic laboratory tool
- A group therapy approach
Correct answer: A patient classification determining fixed reimbursement based on diagnosis, procedures, age, and complications
DRGs classify inpatient stays into groups with fixed payment amounts regardless of actual costs.
Used since 1983, DRG payment equals the weight multiplied by the hospital's base rate. This creates incentives for efficient care and timely discharge. Case managers support this through discharge facilitation and complication prevention.
Question 4: What is the difference between prospective, concurrent, and retrospective utilization review?
- They differ in who performs them
- They differ by timing: prospective before, concurrent during, retrospective after care delivery (Correct answer)
- They are three names for the same process
- They differ by insurance type
Correct answer: They differ by timing: prospective before, concurrent during, retrospective after care delivery
The three types differ by timing relative to care delivery: before, during, and after.
Prospective prevents unnecessary admissions, concurrent optimizes ongoing care with real-time intervention, and retrospective identifies patterns for quality improvement. Case managers are most involved in concurrent review.
Question 5: What is a Medicare Advantage plan?
- A supplemental policy
- An alternative to Original Medicare offered by private insurers providing all Part A/B benefits through managed care (Correct answer)
- Only for military veterans
- A higher-cost version for wealthy beneficiaries
Correct answer: An alternative to Original Medicare offered by private insurers providing all Part A/B benefits through managed care
Medicare Advantage (Part C) is offered by private insurers as an alternative providing Part A/B benefits through managed care networks.
MA plans may add dental, vision, hearing, and drug coverage. They receive capitated per-member-per-month payments from CMS. Case managers must navigate plan-specific networks, authorization requirements, and supplemental benefits.
Question 6: What role does medical necessity play in utilization management?
- A subjective physician opinion that cannot be questioned
- The determination that a service is clinically appropriate and required based on evidence and the individual condition (Correct answer)
- Only applies to emergency services
- Determined solely by insurance financial considerations
Correct answer: The determination that a service is clinically appropriate and required based on evidence and the individual condition
Medical necessity is the evidence-based determination that a service is clinically appropriate and required.
Medical necessity criteria are based on evidence-based guidelines (InterQual, Milliman, MCG). Case managers facilitate determinations by providing comprehensive clinical documentation and arranging peer-to-peer discussions when needed.
CCM - Certified Case Manager Reimbursement and Utilization Management Questions and Answers 2
What is the primary difference between Medicare Part A and Part B?