CCM Reimbursement and Utilization Management 4

Question 1

What is the significance of the 'two-midnight rule' under Medicare?

Accepted Answer

A physician must document an expectation of a hospital stay spanning two midnights to justify inpatient admission under Part A

Answer

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?

Accepted Answer

At least 3 consecutive days as an inpatient (not including the discharge day)

Answer

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'?

Accepted Answer

When an out-of-network provider bills a patient for the difference between their charge and what the insurer paid

Answer

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?

Accepted Answer

To bundle all services related to a specific episode of care into a single payment

Answer

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?

Accepted Answer

18 months

Answer

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.

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Practice Test

CCM Reimbursement and Utilization Management 4