CCM CCM Financial Management & Reimbursement 2 — Questions and Answers
Question 1: Which Medicare part specifically covers prescription drugs for eligible beneficiaries?
- Medicare Part A
- Medicare Part B
- Medicare Part C
- Medicare Part D (Correct answer)
Correct answer: Medicare Part D
Medicare Part D is the optional prescription drug benefit plan available to Medicare beneficiaries.
Question 2: A care manager notices a client is receiving services from a provider outside their HMO network. What financial risk does this create for the client?
- Lower deductible
- Higher or full out-of-pocket costs (Correct answer)
- Automatic prior authorization
- Guaranteed coverage at in-network rates
Correct answer: Higher or full out-of-pocket costs
Out-of-network providers in an HMO typically result in significantly higher or total out-of-pocket costs for the patient, as the plan may not cover those services.
Question 3: Which term describes the process by which a health insurer reviews a request for a specific treatment or medication before it is provided to determine coverage?
- Retrospective review
- Concurrent review
- Prior authorization (Correct answer)
- Utilization audit
Correct answer: Prior authorization
Prior authorization requires insurer approval before a service is rendered to confirm it is medically necessary and covered.
Question 4: A CCM is assisting an uninsured low-income client. Which joint federal-state program should the care manager explore first for potential coverage?
- Medicare
- Medicaid (Correct answer)
- COBRA
- Short-term health plans
Correct answer: Medicaid
Medicaid is a joint federal-state program providing health coverage to eligible low-income individuals and families.
Question 5: Which payment model groups all services related to a single episode of care into one payment, shared among all providers involved?
- Fee-for-service
- Capitation
- Bundled payment (Correct answer)
- Per diem
Correct answer: Bundled payment
Bundled payments cover all services for a defined episode of care under one aggregate payment distributed among participating providers.
Question 6: When a provider bills a patient for the difference between the provider's charge and the insurer's allowable amount, this practice is called:
- Co-billing
- Balance billing (Correct answer)
- Cost-sharing
- Dual eligibility billing
Correct answer: Balance billing
Balance billing occurs when a provider bills the patient for the difference between what was charged and what the insurer paid, which is often prohibited for in-network providers.
CCM CCM Financial Management & Reimbursement 2
Which Medicare part specifically covers prescription drugs for eligible beneficiaries?