CCM - Certified Case Manager Reimbursement and Utilization Management Questions and Answers 2

Question 1

What is the primary difference between Medicare Part A and Part B?

Accepted Answer

Part A covers inpatient/institutional services; Part B covers outpatient/professional/preventive/DME services

Answer

Part A for younger, Part B for older

Answer

Part A is free, Part B has a premium

Answer

Part A covers prescriptions, Part B covers hospitalizations

Question 2

What is prior authorization and the case manager's role?

Accepted Answer

Insurance approval before certain services, with the case manager facilitating clinical documentation

Answer

Authorization before entering a hospital building

Answer

Legal authorization from patient to doctor

Answer

Authorization before case management begins

Question 3

What is a Diagnosis-Related Group (DRG)?

Accepted Answer

A patient classification determining fixed reimbursement based on diagnosis, procedures, age, and complications

Answer

A group of physicians sharing a specialty

Answer

A diagnostic laboratory tool

Answer

A group therapy approach

Question 4

What is the difference between prospective, concurrent, and retrospective utilization review?

Accepted Answer

They differ by timing: prospective before, concurrent during, retrospective after care delivery

Answer

They differ in who performs them

Answer

They are three names for the same process

Answer

They differ by insurance type

Question 5

What is a Medicare Advantage plan?

Accepted Answer

An alternative to Original Medicare offered by private insurers providing all Part A/B benefits through managed care

Answer

A supplemental policy

Answer

Only for military veterans

Answer

A higher-cost version for wealthy beneficiaries

Question 6

What role does medical necessity play in utilization management?

Accepted Answer

The determination that a service is clinically appropriate and required based on evidence and the individual condition

Answer

A subjective physician opinion that cannot be questioned

Answer

Only applies to emergency services

Answer

Determined solely by insurance financial considerations