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
A case manager notices that a physician consistently orders more diagnostic tests than peers for similar patient presentations. This is BEST addressed through:
Answer: Sharing peer comparison data through utilization review feedback
Peer comparison data (benchmarking) provided through utilization review is a constructive, evidence-based method to encourage appropriate practice patterns without undermining clinical authority.
Which of the following BEST describes 'care fragmentation' as it relates to resource waste?
Answer: Lack of coordinated communication leading to duplicated tests and conflicting treatments
Care fragmentation occurs when providers lack shared information, leading to redundant testing, contradictory therapies, and avoidable utilization of resources.
Which approach does a case manager use when applying 'motivational interviewing' in resource management?
Answer: Using empathetic, patient-centered dialogue to enhance patient motivation for self-care behaviors
Motivational interviewing uses open-ended questions, affirmations, and reflective listening to help patients resolve ambivalence and improve adherence, reducing unnecessary resource utilization.
A case manager is conducting a concurrent review for a patient on day 3 of a hospital stay. The primary task is to:
Answer: Assess whether continued inpatient care remains medically necessary
Concurrent review evaluates ongoing medical necessity during a hospital stay to ensure the patient still meets inpatient criteria and that care is progressing toward discharge.
Under the Medicare Two-Midnight Rule, an inpatient admission is generally appropriate when the physician expects the patient to require hospital care for:
Answer: At least two midnights
The Two-Midnight Rule specifies that inpatient admission is appropriate when the physician reasonably expects the patient will need hospital care spanning at least two midnights.
What is the MAIN purpose of a formulary in pharmacy resource management?
Answer: To define approved, cost-effective medications covered by a health plan
A formulary is a list of preferred medications approved by a health plan, balancing clinical effectiveness with cost management to guide prescribing decisions.
Which of the following is an example of a community resource that case managers frequently leverage to address social determinants of health (SDOH)?
Answer: Food banks, transportation programs, and housing assistance services
Community resources such as food banks, transportation, and housing assistance directly address SDOH, reducing health disparities and preventing avoidable medical utilization.