- Certified Case Manager Reimbursement and Utilization Management Questions and Answers Flashcards
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What is the primary difference between Medicare Part A and Part B?
Answer: Part A covers inpatient/institutional services; Part B covers outpatient/professional/preventive/DME services
Part A covers inpatient and institutional services; Part B covers outpatient, professional, and preventive services.
What is prior authorization and the case manager's role?
Answer: Insurance approval before certain services, with the case manager facilitating clinical documentation
Prior authorization requires insurance approval before certain services, with case managers providing clinical justification.
What is a Diagnosis-Related Group (DRG)?
Answer: A patient classification determining fixed reimbursement based on diagnosis, procedures, age, and complications
DRGs classify inpatient stays into groups with fixed payment amounts regardless of actual costs.
What is the difference between prospective, concurrent, and retrospective utilization review?
Answer: They differ by timing: prospective before, concurrent during, retrospective after care delivery
The three types differ by timing relative to care delivery: before, during, and after.
What is a Medicare Advantage plan?
Answer: An alternative to Original Medicare offered by private insurers providing all Part A/B benefits through managed care
Medicare Advantage (Part C) is offered by private insurers as an alternative providing Part A/B benefits through managed care networks.
What role does medical necessity play in utilization management?
Answer: The determination that a service is clinically appropriate and required based on evidence and the individual condition
Medical necessity is the evidence-based determination that a service is clinically appropriate and required.