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
What is the significance of the 'two-midnight rule' under Medicare?
Answer: A physician must document an expectation of a hospital stay spanning two midnights to justify inpatient admission under Part A
The two-midnight rule states that Medicare Part A inpatient payment is generally appropriate when a physician expects a patient's hospital stay to cross two midnights.
A case manager is working with a patient who has Medicare Part A coverage for a skilled nursing facility (SNF) stay. How many days must the patient have been hospitalized before SNF benefits begin?
Answer: At least 3 consecutive days as an inpatient (not including the discharge day)
Medicare Part A SNF benefits require a qualifying inpatient hospital stay of at least 3 consecutive days, not counting the discharge day.
Which of the following best describes 'balance billing'?
Answer: When an out-of-network provider bills a patient for the difference between their charge and what the insurer paid
Balance billing occurs when an out-of-network provider charges the patient the difference between their billed amount and the insurer's allowed amount.
What is the primary purpose of a case rate (also known as a global payment) in healthcare reimbursement?
Answer: To bundle all services related to a specific episode of care into a single payment
A case rate bundles payment for an entire episode of care (e.g., a maternity delivery) into one fixed fee covering all related services.
Under COBRA, how long may a qualified beneficiary typically continue group health coverage after leaving employment due to voluntary resignation?
Answer: 18 months
COBRA generally allows up to 18 months of continuation coverage for employees and dependents who lose coverage due to a qualifying event such as voluntary termination.
Which Medicare Advantage plan type requires members to choose a primary care physician and get referrals to see specialists?
Answer: Health Maintenance Organization (HMO)
Medicare Advantage HMO plans typically require members to designate a PCP who coordinates care and provides referrals to in-network specialists.
A payer's utilization review nurse denies continued inpatient days citing InterQual or Milliman criteria. What does this mean?
Answer: The patient's clinical status no longer meets established evidence-based criteria for acute inpatient level of care
InterQual and Milliman are nationally recognized clinical criteria sets used by payers to determine whether inpatient care is medically necessary.