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 purpose of a 'remittance advice' (RA) sent by an insurer to a provider?
Answer: To explain the payment decisions made on submitted claims, including amounts paid, adjusted, and denied
A remittance advice (RA) details how each claim was adjudicated, including payments, contractual adjustments, and denial reasons.
Which federal act prohibits providers from knowingly submitting false or fraudulent claims to federal healthcare programs?
Answer: The False Claims Act (FCA)
The False Claims Act imposes civil liability on entities that submit fraudulent claims to government programs, including Medicare and Medicaid.
A case manager notices a pattern of a physician ordering the same high-cost test for every patient regardless of diagnosis. This is MOST likely an example of:
Answer: Overutilization
Ordering tests indiscriminately without clinical indication represents overutilization, which drives up costs without improving outcomes.
Which of the following is a core difference between Medicare Part C (Medicare Advantage) and traditional Medicare?
Answer: Medicare Advantage plans are offered by private insurers approved by CMS and may include additional benefits beyond Parts A and B
Medicare Advantage plans are private insurance alternatives to traditional Medicare that often include extra benefits like dental, vision, and Part D drug coverage.
When a managed care organization contracts with a hospital to pay $1,200 per inpatient day regardless of diagnosis or services provided, this arrangement is called:
Answer: Per diem reimbursement
Per diem reimbursement pays a flat daily rate for inpatient care, incentivizing shorter lengths of stay since each additional day pays the same rate.
Under the ACA's essential health benefits (EHBs), which of the following services MUST be covered by individual and small-group health plans?
Answer: Emergency services, mental health services, and preventive care
The ACA mandates coverage of 10 essential health benefit categories, including emergency services, mental health and substance use disorder services, and preventive care.
A case manager learns that a patient's claim was denied because the provider was not in the insurer's network. The patient visited this provider due to a true emergency. Which federal law most likely protects this patient from higher out-of-network cost-sharing?
Answer: The No Surprises Act
The No Surprises Act protects patients from unexpected out-of-network charges for emergency care and certain non-emergency services at in-network facilities.