Resource Management & Utilization Flashcards
7 cards from real CCM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Resource Management & Utilization flashcards as text
Which federal law established the Prospective Payment System (PPS) for Medicare inpatient hospital stays, directly impacting resource utilization?
Answer: The Social Security Amendments of 1983
The 1983 Social Security Amendments created the DRG-based Prospective Payment System, incentivizing hospitals to manage resource use and reduce unnecessary inpatient days.
A case manager is evaluating whether a patient meets criteria for acute inpatient admission versus observation status. Which tool is MOST commonly used for this determination?
Answer: InterQual or Milliman Care Guidelines
InterQual and Milliman Care Guidelines are evidence-based clinical criteria tools used to determine appropriate level of care and medical necessity.
What is the primary goal of a disease management program from a resource utilization perspective?
Answer: To reduce complications and hospitalizations through proactive chronic disease monitoring
Disease management programs target high-risk chronic disease patients to prevent acute exacerbations, reduce costly hospitalizations, and improve health outcomes.
In a value-based care model, case managers are MOST focused on:
Answer: Achieving quality outcomes while managing cost efficiency
Value-based care aligns financial incentives with quality and efficiency, making cost-effective, outcome-driven resource use the central case management priority.
A patient with a complex chronic condition is being discharged from the hospital. Which post-acute resource is MOST appropriate for a patient requiring daily skilled nursing care but not 24-hour medical supervision?
Answer: Skilled nursing facility (SNF)
A skilled nursing facility provides daily skilled nursing and therapy services for patients who are medically stable but not yet ready for home, making it the appropriate step-down option.
Which metric is MOST useful for a case manager evaluating the effectiveness of resource management interventions?
Answer: 30-day hospital readmission rate
The 30-day readmission rate is a widely accepted quality and utilization metric that reflects whether care transitions and resource coordination successfully prevented repeat hospitalizations.
What is 'steerage' in the context of managed care resource management?
Answer: The process of directing patients toward preferred, in-network, or high-value providers
Steerage involves guiding patients to in-network or high-value providers to optimize cost and quality, a key managed care strategy for resource management.