CCM Reimbursement and Utilization Management 3 — Questions and Answers
Question 1: Which utilization management strategy involves evaluating a proposed service BEFORE it is provided to determine medical necessity?
- Retrospective review
- Concurrent review
- Prospective review (prior authorization) (Correct answer)
- Peer-to-peer review
Correct answer: Prospective review (prior authorization)
Prospective review, commonly known as prior authorization or pre-certification, assesses medical necessity before a service is delivered.
Question 2: Which of the following best defines a 'carve-out' benefit in managed care?
- A benefit excluded from the standard plan but covered under a separate specialized contract (Correct answer)
- A provider who has opted out of the insurer's network
- A co-payment waived for preventive services
- A benefit that exceeds the annual maximum allowed by the plan
Correct answer: A benefit excluded from the standard plan but covered under a separate specialized contract
Carve-out benefits, such as behavioral health or pharmacy, are separated from the main medical plan and managed by a specialty vendor.
Question 3: Under the Mental Health Parity and Addiction Equity Act (MHPAEA), how must insurers treat mental health and substance use disorder benefits?
- Mental health benefits must have lower cost-sharing than medical benefits
- Mental health benefits may be offered only if the insurer chooses to include them
- Mental health benefits cannot be subject to more restrictive limitations than comparable medical/surgical benefits (Correct answer)
- Mental health visits are capped at 30 per year regardless of medical necessity
Correct answer: Mental health benefits cannot be subject to more restrictive limitations than comparable medical/surgical benefits
MHPAEA prohibits insurers from imposing more restrictive financial requirements or treatment limitations on mental health/SUD benefits than on medical/surgical benefits.
Question 4: A case manager identifies that a patient is being kept in an acute care bed primarily for social reasons, not medical ones. What is the most appropriate action?
- Request a 7-day extension from the payer
- Initiate discharge planning to identify appropriate post-acute or community resources (Correct answer)
- Document the social issues and take no further action
- Notify the physician that the patient must leave immediately
Correct answer: Initiate discharge planning to identify appropriate post-acute or community resources
When medical necessity for acute care no longer exists, the case manager should proactively identify appropriate placement or community supports.
Question 5: What is the primary function of a formulary in pharmacy benefit management?
- A list of approved pharmacies in the insurer's network
- A tiered list of covered medications used to guide prescribing and control drug costs (Correct answer)
- A government-mandated list of generic drug substitutions
- A clinical protocol for managing chronic disease with medications
Correct answer: A tiered list of covered medications used to guide prescribing and control drug costs
A formulary is a preferred drug list organized in tiers that determines coverage level and cost-sharing for medications.
Question 6: Which entity is responsible for conducting Independent Medical Reviews (IMRs) when a health plan denies a claim?
- The treating physician
- The state insurance department or a contracted independent review organization (IRO) (Correct answer)
- The Centers for Medicare & Medicaid Services (CMS)
- The employer's human resources department
Correct answer: The state insurance department or a contracted independent review organization (IRO)
IMRs are conducted by independent review organizations contracted by state regulators to provide an impartial second opinion on disputed claim denials.
Question 7: In the context of managed care, what does 'step therapy' require a patient to do?
- Attend physical therapy before receiving surgery authorization
- Try a first-line (usually less expensive) treatment before a payer will cover a preferred or specialty medication (Correct answer)
- Obtain a specialist referral before seeing a primary care provider
- Complete a wellness program before enrollment in a high-cost plan
Correct answer: Try a first-line (usually less expensive) treatment before a payer will cover a preferred or specialty medication
Step therapy protocols require patients to try and fail lower-cost treatment options before a payer will authorize more expensive alternatives.
CCM Reimbursement and Utilization Management 3
Which utilization management strategy involves evaluating a proposed service BEFORE it is provided to determine medical necessity?