CCM - Certified Case Manager Reimbursement and Utilization Management Questions and Answers

Question 1

A case manager is performing a utilization review for a patient who has been hospitalized for five days following a complex surgical procedure.
The review is focused on assessing the medical necessity of continued hospitalization and planning for the next level of care.
Which type of utilization review is the case manager conducting?

Accepted Answer

Concurrent Review

Answer

Prospective Review

Answer

Retrospective Review

Answer

Appeals Review

Question 2

A hospital is reimbursed a single, pre-determined payment for all services related to a total knee replacement, including the surgery, hospital stay, and post-operative physical therapy. This reimbursement model is an example of:

Accepted Answer

Bundled Payment

Answer

Fee-for-Service (FFS)

Answer

Capitation

Answer

Per Diem

Question 3

Which of the following is the PRIMARY goal of utilization management in case management?

Accepted Answer

To ensure patients receive appropriate, medically necessary, and cost-effective care.

Answer

To deny services to reduce insurer's costs.

Answer

To expedite patient discharge regardless of clinical readiness.

Answer

To shift financial risk exclusively to the healthcare provider.

Question 4

A case manager is working with a client who has been denied coverage for a new, expensive medication prescribed by their specialist. The case manager reviews the client's policy, gathers supporting clinical documentation from the physician, and submits a formal request to the insurance company to reconsider the denial. This process is known as:

Accepted Answer

Appeals Process

Answer

Concurrent Review

Answer

Preauthorization

Answer

Retrospective Review

Question 5

A reimbursement model where a hospital is paid a fixed amount for a patient's entire admission based on their diagnosis, regardless of the actual cost of care, is known as a:

Accepted Answer

Prospective Payment System (PPS)

Answer

Fee-for-Service (FFS) System

Answer

Cost-Plus Reimbursement System

Answer

Value-Based Purchasing (VBP) System

Question 6

When a case manager uses standardized, evidence-based clinical criteria like InterQual or MCG to determine the medical necessity and appropriateness of a patient's admission or continued stay, what function are they performing?

Accepted Answer

Utilization Review

Answer

Discharge Planning

Answer

Benefit Determination

Answer

Risk Management