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 is evaluating a patient for home health services. Which of the following is a Medicare eligibility requirement for home health coverage?
Answer: Patient must be homebound and require skilled care
Medicare home health requires that the patient be homebound and need intermittent skilled nursing, physical therapy, speech therapy, or occupational therapy.
Which data source would a case manager MOST likely use to identify high-risk patients for proactive outreach in a population health model?
Answer: Predictive analytics models using claims and clinical data
Predictive analytics tools analyze claims and clinical data to identify high-risk individuals likely to experience costly health events, enabling proactive case management outreach.
In the context of resource management, what does 'utilization creep' refer to?
Answer: The slow, incremental overuse of healthcare services beyond what is clinically indicated
Utilization creep describes the gradual increase in service use over time without corresponding improvement in clinical outcomes, representing wasteful resource consumption.
A case manager working in a Workers' Compensation case must primarily balance the interests of:
Answer: The injured worker's recovery and return-to-work goals with cost management for the payer
In Workers' Compensation, the case manager advocates for the injured worker's functional recovery and return to work while managing resources effectively for the payer.
Which of the following BEST describes a 'carve-out' in managed care resource management?
Answer: A specific benefit category (e.g., behavioral health) managed separately from the main health plan
A carve-out separates a specific benefit — commonly behavioral health or pharmacy — from the main health plan and manages it through a specialized entity to control costs and quality.
A case manager identifies that a patient's avoidable hospital readmission was due to medication non-adherence. The MOST appropriate resource-based intervention is:
Answer: Coordinating medication reconciliation, pharmacy counseling, and follow-up monitoring
Medication reconciliation, pharmacist counseling, and post-discharge monitoring address the root cause of non-adherence and reduce the risk of future avoidable readmissions.
Which concept describes the financial risk arrangement where a provider group receives a fixed per-member-per-month payment to cover all care for a defined population?
Answer: Capitation
Capitation is a payment model in which providers receive a fixed monthly amount per enrolled member, incentivizing efficient resource management to keep costs within the capitated budget.