CCM Reimbursement and Utilization Management 4 — Questions and Answers
Question 1: What is the significance of the 'two-midnight rule' under Medicare?
- Patients must be observed for two midnights before being eligible for Medicare Part A benefits
- A physician must document an expectation of a hospital stay spanning two midnights to justify inpatient admission under Part A (Correct answer)
- Medicare will only pay for the first two midnight hours of an ER visit
- Inpatient rehabilitation requires a two-midnight qualifying stay in acute care
Correct answer: A physician must document an expectation of a hospital stay spanning two midnights to justify inpatient admission under Part A
The two-midnight rule states that Medicare Part A inpatient payment is generally appropriate when a physician expects a patient's hospital stay to cross two midnights.
Question 2: A case manager is working with a patient who has Medicare Part A coverage for a skilled nursing facility (SNF) stay. How many days must the patient have been hospitalized before SNF benefits begin?
- No qualifying hospital stay is required
- At least 3 consecutive days as an inpatient (not including the discharge day) (Correct answer)
- At least 5 consecutive days as an inpatient
- At least 7 consecutive days as an inpatient
Correct answer: At least 3 consecutive days as an inpatient (not including the discharge day)
Medicare Part A SNF benefits require a qualifying inpatient hospital stay of at least 3 consecutive days, not counting the discharge day.
Question 3: Which of the following best describes 'balance billing'?
- The process of billing a secondary insurer after the primary pays
- When an out-of-network provider bills a patient for the difference between their charge and what the insurer paid (Correct answer)
- A method of spreading large medical bills across multiple months
- When a provider waives a patient's co-payment
Correct answer: When an out-of-network provider bills a patient for the difference between their charge and what the insurer paid
Balance billing occurs when an out-of-network provider charges the patient the difference between their billed amount and the insurer's allowed amount.
Question 4: What is the primary purpose of a case rate (also known as a global payment) in healthcare reimbursement?
- To pay providers based on the number of patients enrolled in their panel
- To bundle all services related to a specific episode of care into a single payment (Correct answer)
- To reimburse providers based on documented costs plus a fixed profit margin
- To establish the maximum allowable charge for individual CPT codes
Correct answer: To bundle all services related to a specific episode of care into a single payment
A case rate bundles payment for an entire episode of care (e.g., a maternity delivery) into one fixed fee covering all related services.
Question 5: Under COBRA, how long may a qualified beneficiary typically continue group health coverage after leaving employment due to voluntary resignation?
- 18 months (Correct answer)
- 24 months
- 36 months
- 12 months
Correct answer: 18 months
COBRA generally allows up to 18 months of continuation coverage for employees and dependents who lose coverage due to a qualifying event such as voluntary termination.
Question 6: Which Medicare Advantage plan type requires members to choose a primary care physician and get referrals to see specialists?
- Preferred Provider Organization (PPO)
- Private Fee-for-Service (PFFS)
- Health Maintenance Organization (HMO) (Correct answer)
- Medical Savings Account (MSA)
Correct answer: Health Maintenance Organization (HMO)
Medicare Advantage HMO plans typically require members to designate a PCP who coordinates care and provides referrals to in-network specialists.
Question 7: A payer's utilization review nurse denies continued inpatient days citing InterQual or Milliman criteria. What does this mean?
- The patient has reached their lifetime maximum benefit
- The patient's clinical status no longer meets established evidence-based criteria for acute inpatient level of care (Correct answer)
- The payer is refusing all future claims from this hospital
- The physician must perform surgery within 24 hours or the case will be closed
Correct answer: The patient's clinical status no longer meets established evidence-based criteria for acute inpatient level of care
InterQual and Milliman are nationally recognized clinical criteria sets used by payers to determine whether inpatient care is medically necessary.
CCM Reimbursement and Utilization Management 4
What is the significance of the 'two-midnight rule' under Medicare?