Reimbursement and Utilization Management 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 Reimbursement and Utilization Management flashcards as text
A patient's insurer denies a claim stating the service was 'not medically necessary.' What is the case manager's FIRST step?
Answer: Review the clinical criteria used for the denial and compare with the patient's documentation
Reviewing the denial criteria against clinical documentation helps identify whether a peer-to-peer review or formal appeal is warranted.
Which payment model reimburses a provider a fixed amount per member per month regardless of services rendered?
Answer: Capitation
Capitation pays a set monthly fee per enrolled member, transferring financial risk to the provider.
Under Medicare, what is the purpose of the Advance Beneficiary Notice (ABN)?
Answer: To inform a beneficiary that Medicare may not cover a service so they can decide whether to proceed
An ABN alerts Medicare beneficiaries in advance that a specific service may be denied, allowing an informed financial decision.
A case manager is conducting concurrent review for an inpatient stay. What is the primary goal of this activity?
Answer: Ensure continued hospitalization is medically justified and facilitate timely discharge planning
Concurrent review monitors ongoing medical necessity for inpatient care and promotes efficient, appropriate length of stay.
Which federal program provides health coverage to individuals with end-stage renal disease (ESRD) regardless of age?
Answer: Medicare
Medicare covers individuals with ESRD under a special entitlement, making age irrelevant for this specific condition.
What does the term 'usual, customary, and reasonable' (UCR) refer to in insurance billing?
Answer: The average amount charged by providers in a geographic area for the same service
UCR represents the prevailing fee for a given service in a specific region and is used to determine out-of-network payment levels.
A hospital is paid a flat rate for an entire episode of care regardless of the patient's actual length of stay or services used. This best describes which payment method?
Answer: Diagnosis-Related Group (DRG) payment
DRG-based payment bundles reimbursement for an entire inpatient stay into a single predetermined amount tied to diagnosis.