CCM Financial Management & Reimbursement Flashcards

Which Medicare part specifically covers prescription drugs for eligible beneficiaries?

Answer: Medicare Part D

Medicare Part D is the optional prescription drug benefit plan available to Medicare beneficiaries.

A care manager notices a client is receiving services from a provider outside their HMO network. What financial risk does this create for the client?

Answer: Higher or full out-of-pocket costs

Out-of-network providers in an HMO typically result in significantly higher or total out-of-pocket costs for the patient, as the plan may not cover those services.

Which term describes the process by which a health insurer reviews a request for a specific treatment or medication before it is provided to determine coverage?

Answer: Prior authorization

Prior authorization requires insurer approval before a service is rendered to confirm it is medically necessary and covered.

A CCM is assisting an uninsured low-income client. Which joint federal-state program should the care manager explore first for potential coverage?

Answer: Medicaid

Medicaid is a joint federal-state program providing health coverage to eligible low-income individuals and families.

Which payment model groups all services related to a single episode of care into one payment, shared among all providers involved?

Answer: Bundled payment

Bundled payments cover all services for a defined episode of care under one aggregate payment distributed among participating providers.

When a provider bills a patient for the difference between the provider's charge and the insurer's allowable amount, this practice is called:

Answer: Balance billing

Balance billing occurs when a provider bills the patient for the difference between what was charged and what the insurer paid, which is often prohibited for in-network providers.