Certified Case Manager Reimbursement and Utilization Management 1 Flashcards

A health plan pays a primary care physician a fixed monthly fee per enrolled patient, regardless of how many services that patient uses. This payment arrangement is called:

Answer: Capitation

Capitation is a payment model in which a provider receives a set amount per member per month (PMPM) in exchange for agreeing to deliver covered services to that member, shifting financial risk from the payer to the provider.

A Medicare beneficiary is kept in a hospital bed and receiving tests and treatment, but the physician has not written a formal inpatient admission order. This patient is most likely classified under which status?

Answer: Observation status

Observation status is an outpatient classification. Medicare bills observation stays under Part B, not Part A, which means the beneficiary may face higher cost-sharing and the stay does not count toward the three-day inpatient requirement needed to qualify for SNF coverage.

When a claim is denied by a managed care organization, the case manager's first recommended step in advocating for the patient is to:

Answer: Initiate a formal internal appeal using clinical documentation to support medical necessity

The internal appeal process is the required first step before escalating to external review. Case managers strengthen appeals by submitting clinical notes, evidence-based guidelines, and peer-reviewed literature that support the medical necessity of the denied service.

A patient covered by both a group employer health plan and a spouse's employer health plan needs surgery. The case manager must determine which plan pays first. This process is known as:

Answer: Coordination of benefits (COB)

Coordination of benefits (COB) is the process used when a patient has dual coverage to determine which plan is primary (pays first) and which is secondary (pays remaining costs), preventing total reimbursements from exceeding 100% of the claim.

Under a value-based purchasing (VBP) program, a hospital's Medicare reimbursement is adjusted based on:

Answer: Performance on quality metrics such as patient outcomes and satisfaction scores

Value-based purchasing ties a portion of hospital Medicare payments to performance on quality and safety measures—including clinical process measures, patient experience scores, and outcomes—shifting incentives from volume to value.

A utilization management nurse contacts the treating physician because the patient's continued inpatient stay no longer meets established clinical criteria for acute care. The most appropriate next action for the case manager is to:

Answer: Initiate a discharge planning conversation and explore appropriate lower levels of care

When a patient no longer meets inpatient criteria, the case manager's role is to collaborate with the care team to plan a timely transition to the most appropriate and cost-effective care setting—such as a skilled nursing facility, home health, or outpatient rehabilitation—rather than acting unilaterally or prematurely.